Healthcare in South Africa

South Africa is a huge, sprawling country at the foot of the African continent. It covers 1.2 million square kilometers (463,322 square miles), with a population of more than 43 million, mostly city-based. Since apartheid ended in 1994, there has been a massive shift from racially biased, hospital-based curative care, towards easily accessible primary healthcare.

Q: What kind of health system does South Africa have?

A: Both private and public, with a grave disparity between the two, which reflects the country's first world/third world dichotomy. Annually, the government spends the equivalent of approximately US$3.1 billion (at a late April 2002 exchange rate) on 35 million people, while the private sector spends US$36.5 billion on just seven million. The private sector, bristling with sophisticated technology, serves just 16% of the population – those with private health insurance. There are more than 200 private hospitals, owned by consortia of private physicians or large corporations. Private hospital beds number 24,537, public ones 110,143. Public healthcare is free to pregnant women and children under six; others pay on a means-tested, fee-for-service basis.

The gross inequity between the two sectors has led health ministers to threaten regulation, requiring the private sector to obtain a "certificate of need" from the Department of Health before a major purchase, such as an MRI scanner, can be made. The aim is to redirect scarce resources to areas of greatest need. Currently, services are not equitably distributed: for instance, there are 50 MRI scanners in the private sector while there are only four in the public service. Public/private partnerships are appearing with, for example, public hospitals leasing surplus wards to the private sector, and sharing their specialists. National Health Insurance is under discussion.

Q: How are the different systems funded?

A: Private health insurance fees are split 50/50 between employers and employees. However, faced with medical inflation on one hand and legislation to enforce 25% solvency reserves on the other, medical insurance plans are struggling. There have been spectacular collapses and many mergers. Managed healthcare has featured big, as have innovative savings schemes. People may buy limited coverage or choose to pay for flu medication, for example, out of their own pockets and save their medical insurance contribution for a big operation. Some firms have cut costs by choosing lesser plans, leaving unwary employees to face unexpected bills, which often force them into the public sector. The public service is funded at federal (20%) and provincial (80%) levels. There is serious discrepancy in health spending between the nine provinces, with some rural ones actually cutting health budgets in favor of education.

Q: Who uses the public service, who the private?

A: Besides the seven million with private health insurance, an estimated 30% of those without insurance occasionally consult doctors on a direct-paying basis. However, 40% of the population lives in dire poverty and lacks that choice. Payment for treatment is on a sliding scale in accordance with income and number of dependents; if a family is unable to bear the cost in terms of the standard means test, the treatment will be partly or entirely financed by the government. About 80% of these people consult traditional healers, some of whom are trained by the Department of Health to provide primary healthcare. There are 6.9 million low-paid, blue-collar workers with no medical insurance, and there is pressure to provide less sophisticated, low-cost schemes. But with health insurance contributions rising to an estimated 30% of people's incomes by 2007, it's likely that pressure on the public service will grow.

Q: What is the quality of care in each system?

A: The private system is excellent: the United Nations ranked South Africa's private system 39 out of 162 nations for technological innovation and achievement. Worldwide, people fly to South Africa for operations, which are relatively cheap because of the country's weak currency. In the public sector, standards vary according to location. Large, urban teaching hospitals offer good, if clogged-up, service. But despite a massive building program, many rural hospitals are run-down, with broken equipment, two patients per bed, and a shortage of basic medicine. Ambulances are worn out. There is a dire shortage of radiographers, dieticians, physiotherapists, and nurses. Since 88% of doctors work in metropolitan areas, there is a shortage of doctors in remote areas (the ratio varies from 1:650 people in the Western Cape to 1:30,000 in parts of the Eastern Cape) due to low salaries, lack of infrastructure, etc. On the plus side, more than 500 new clinics now stand in areas where formerly people used to walk seven hours for treatment. The national rail carrier, Transnet, operates a healthcare train (the Phelophepa Train) that brings affordable healthcare to many rural communities.

Q: What are current concerns among healthcare workers?

A: There are many. The most pressing include: low pay; despair about AIDS and the government's reluctance to provide clear treatment guidelines; lack of basic infrastructure such as roads and telephones in remote rural areas, which makes TB testing difficult (South Africa has the highest TB rates in the world, fanned by HIV); and the growth of multi-drug resistant TB, which has already killed health workers.

Q: What are the current concerns among patients?

A: Among private patients, that healthcare will become unaffordable. Among public patients, poverty-related illnesses, including TB, malaria, cholera, hepatitis B, and measles. Malnutrition is rife – stunting affects up to 27% of children. About 2.5 million people are malnourished and a further 14 million at risk. There is concern that the massive poverty-alleviation program, together with improvements in water supply, sanitation, nutrition, and vaccination, could be submerged by the tidal wave of HIV. Already AIDS patients fill 40% of beds in some hospitals.

Q: What are the current challenges in providing healthcare?

A: AIDS, AIDS, and AIDS. There are 2.4 million HIV-infected people in South Africa. Already Johannesburg hospitals admit 100 full-blown cases daily. Also, South Africa has become a target for drug traffickers and gang lords, and the country can ill afford the high rate of MVAs, gunshot wounds, and stabbings.

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