South Africa

A story of health care in South Africa

This doctor in a rural part of South Africa had to hike along the coast in order to provide medicine and care to a remote clinic on the Wild Coast of the country. If he had not made this decision, the people in the clinic would not have had access to any clinical services, or the medication he brought. In order to understand how situations like this are even possible in South Africa, there are a few things you need to know about the country. This part of the project aims to provide you with the context you need to understand healthcare in South Africa.

“There was a protest over electricity. Cars and people were blocked from using the road but John did not allow that to prevent him from carrying out his duties,” said the hospital’s CEO, Nontsikelelo Matebese. “He wrapped the medication in plastics and put them inside a bag. He had to walk barefoot and at some point he had to swim through the river, as it had rained previously.”

Njilo, N. (2019). Rural doctor hiked, swam across river to reach patients. The Sowetan.

Cape Town is located near the most southerly point of Africa and is one of the most scenic cities in the world in terms of geography and access to natural beauty.

Social and health inequality

Unfortunately, South Africa is also one of the most unequal societies in the world. According to Statistics South Africa, the Gini coefficient measuring relative wealth recently reached 0.69 based on income data (including salaries, wages, and social grants), making South Africa one of the most unequal societies in the world.

South Africa’s Gini coefficient (see at the top of the graph) For comparison, compared with the Gini coefficients of Brazil and Norway, showing clearly that the difference between rich and poor in South Africa is significantly higher than the other countries. Interestingly, note that Brazil’s level of inequality in the 1990s was similar to where South Africa is today but has improved markedly in the last 20 years. This shows that it is possible for a country to reduce inequality.

The poorest 20% of the South African population consume less than 3% of total expenditure, while the wealthiest 20% consume 65%, which means that, while the richest people in South Africa have access to a quality of life that rivals any European country, the poorest people are subject to abject poverty, living in makeshift houses without running water, electricity or relative safety even from the elements.

A picture of the Khayelitsha township, as seen from the N2, the national road running from the airport into the city. Soon after arriving in Cape Town, this is the stark reminder that there are 2 South Africa’s.

There’s no dispute that South Africa’s health care system needs major reforms. There are considerable inequities in health care between urban and rural areas; between public and private health sectors and between primary health care and hospital care. The private and public health systems exist in parallel, where the public system serves the majority of the population but is underfunded and understaffed. South Africa spends about 8.6% of its Gross Domestic Product on health (about US$437 per capita). Of this, half is spent in the private sector which provides services for the richest 16% of the country’s citizens. The remaining 84% of the population depend on services provided in the public sector.

South Africa has poor health outcomes compared to other middle-income countries such as Brazil with similar health spending as a percentage of GDP. It spends more than R300 billion – or around 8.5% of its gross domestic product – on health care. But half is spent in the private sector catering for people who are well off while the remaining 84% of the population, which carries a far greater burden of disease, depends on the under-resourced public sector.

Rispel, L. (2018). South Africa’s universal health care plan falls short of fixing an ailing system. The Conversation.

It is estimated that in South Africa over 70% of doctors work in the private sector, leaving just over 27% to serve the vast majority in the public sector. The unequal health care distribution favours richer people, even though illness is greater for poorer people. The socio-economic reality of South Africa means that access to high-quality health care is reserved for those who can afford it, while the rest of the population must depend on an overburdened and under-resourced public health system.

Health structure and policy

In 1994, when apartheid ended, the health system faced massive challenges, many of which still persist. Macroeconomic policies, fostering growth rather than redistribution, contributed to the persistence of economic disparities between races despite a large expansion in social grants. The public health system has been transformed into an integrated, comprehensive national service, but failures in leadership and stewardship and weak management have led to inadequate implementation of what are often good policies.

Coovadia, H., Jewkes, R., Barron, P., Sanders, D. & McIntyre, D. (2009). The health and health system of South Africa: historical roots of current public health challenges. The Lancet, 374:817-834.

The South African health system is structured in the following way:

  1. Primary
  2. Secondary
  3. Tertiary

The South African healthcare system is based on the Primary Health Care (PHC) model, which has a vision of health care as caring for people, rather than treating diseases. PHC consists of three main areas:

  • Empowered people and communities.
  • Multisectoral policy and action.
  • Primary care and essential public health functions as the core of integrated health services.

In the 20 years since South Africa underwent a peaceful transition from apartheid to a constitutional democracy, considerable social progress has been made toward reversing the discriminatory practices that pervaded all aspects of life before 1994. Yet the health and well-being of most South Africans remain plagued by a relentless burden of infectious and noncommunicable diseases, persisting social disparities, and inadequate human resources to provide care for a growing population with a rising tide of refugees and economic migrants.

Myosi, B. & Benatar, S. (2014). Health and Health Care in South Africa — 20 Years after Mandela. New England Journal of Medicine, 371:1344-1353.

The South African Constitution guarantees everyone “access to health care services” and states that “no one may be refused emergency medical treatment.” This means that all South African residents, including refugees and asylum seekers, are entitled to access to health care services, including access to free anti-retroviral treatment at all public health care providers. The Refugee Act entitles migrants to full legal protection under the Bill of Rights as well as the same basic health care services which inhabitants of South Africa receive.

Rural and urban access to services

In 2009, Coovadia et al. raised important concerns about the direction that the healthcare system was moving taking into account the deep historical roots of the problem. It is clear that, a decade later, they were right to be concerned. The South African health system remains dysfunctional, unable to provide for the needs of more than 80% of the country. Nowhere is this more evident than for many South African citizens living in rural and remote areas of the country. Rural communities in South Africa, similar to other countries worldwide, have less access to health care. Facilities are limited, the information provided to patients is insufficient, and there are fewer health professionals to attend to the population, which results in them having a poorer health status.

One of the challenges is in recruiting students from rural areas to study as health professionals and then return to their communities. Studies have shown that the students’ background is one of the most important factors in retaining community-based health professionals. However, there are challenges in recruiting students who are able to gain access to professional programmes at university (often because of poor primary and secondary education in rural areas, as well as a lack of access to funding for education), as well as in retaining them when they return home after studying. Poor working conditions and corrupt and inefficient management systems make it difficult for rural health professionals to work effectively, even when they are motivated to do so.

The photo series and video that are presented below were produced by Sarah Manig, a UWC postgraduate student who completed her MSc degree in a rural area of the Eastern Cape. It is reproduced here with permission from Sarah and her research participants. They provide some insight into the challenges of accessing health services in remote parts of the country.

This video was created by Sarah Manig, a postgraduate student with an interest in community-based rehabilitation, in the Department of Physiotherapy at UWC, as part of her Master’s project in 2017. Sarah’s project focused on the needs of community members who had undergone lower limb amputations, living in rural parts of the Eastern Cape in South Africa.

Socioeconomic challenges

It has become increasingly evident that corruption is a major contributing factor to the quality of service provision in South African healthcare. Corruption has a negative effect on patient care and on the morale of healthcare workers who are often aware of the corrupt actions – as well as perpetrators – but who feel that they are unable to take action to address the problem. It is difficult to determine the extent and exact nature of the corruption in the health system but it is clear that it accounts for a significant proportion of the lack of resources that is so evident in practice. “Irregular expenditure” reflects spending that does not comply with the necessary rules and regulations and while it may not always be directly linked to corruption, corruption always involved irregular activities. In the period between 2009 and 2012, irregular expenditure amounted to R5.3 billion (US$533 million) in one province alone.

In order to reduce the level of corruption in health services, South Africa needs the political will to run corruption-free health services, an effective government that enforces laws, and citizen involvement and advocacy to hold public officials accountable. However, for various reasons, these all bring their own challenges. It is clear that more laws are not the answer, as South African legal institutions have extensive powers to hold people accountable for their actions. The problem is cultural and socioeconomic and will, therefore, require interventions that go beyond calls for stronger punishment for those involved.

“Mitchells Plain Community Health Centre is the only day hospital where you have to wait this long. I have been to day hospitals at Hanover Park and Manenberg and I usually get helped within two hours. The only reason I don’t always go to the day hospital in Hanover Park is because the gangsterism makes it dangerous.”

Dirk, N. & Villette, F. (2015). Health centre can’t cope: angry patients. Independent online.

In addition to challenges faced at the systemic level, patients attending clinics in certain areas of the country face considerable personal risk as a result of the high levels of violence in South Africa.

HIV and TB

National Health Insurance plan

The health system performs poorly due to a combination of factors including the poor management of public sector hospitals, health professional shortages (particularly in rural areas), low productivity levels among staff, escalating private health care costs and poor quality of care. One of the ways in which the government is trying to address these issues is with the implementation of the National Health Insurance plan (NHI), which has the goal of providing first-class public healthcare. In theory, the NHI plan has a vision of providing equitable access to health services, regardless of a person’s ability to pay or whether they live in an urban or rural area. The consolidated insurance fund will see public and private revenue integrated into one funding pool, which will enable cross-subsidisation and ensuring that essential services are made available.

However, the plan is already being challenged for several reasons, including the following:

  • It focuses on curative services instead of taking a public health approach which would focus on disease prevention, health promotion and health protection.
  • It doesn’t address the relationship between the public and private health sectors.
  • It adds additional layers of management, which raises concerns about lines of communication and increasing the amount of administration required to pay service providers.
  • More bureaucracy has a tendency to provide more opportunities for corruption and inefficiency, already a major problem in the health system.

In addition, the plan is only going to be initiated in 2026 and will come at a cost of two hundred and fifty-six billion rands. This funding is likely to come from citizens who will see increases in the level of tax they pay, making the system more closely aligned with other countries, where high taxes subsidise the government’s provision of services. The plan is not without opposition though, with some arguing that it will introduce other problems into the system. For example, there is likely to be an associated loss of employment for staff in the private sector as they struggle to compete with the NHI system. There are also concerns that the government is simply not able to manage a project of this scale and importance, as is evident by their inept handling of the country’s power supply, airline, and public broadcaster.

It is clear that the NHI plan is am important first step towards developing a more equitable health system in the country, but also equally clear that it falls short of providing a solution to many of the deeper, more complex, socioeconomic problems that are part of South African healthcare.

Physio in SA healthcare

  • The number of physiotherapists in the country expressed as per 1000 or 10 000? This will provide a bit of how we work as physiotherapists.
  • Do we know how we work as physiotherapists in South Africa, i.e. either promotive or curative, and not what is stated in our Charter internationally or locally as a philosophy?
  • Maybe some evidence on how physiotherapy rehabilitation and practice responded to the burden of disease or have been upscaled. It could be nice to reflect on whether we are getting healthier on local and International level and do we address important outcomes.

Conclusion

Reading material

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