The health and health system of South Africa: Historical roots of current public health challenges

August 24, 2009

The first paper is written by Professor Hoosen Coovadia, Director: HIV Management, University of the Witwatersrand, Johannesburg; and Victor Daitz Professor of HIV/AIDS Research, University of Kwazulu-Natal, Durban, and colleagues, and details the health history of SA. The authors say: "The roots of a dysfunctional health system and the collision of the epidemics of communicable and non-communicable diseases in South Africa can be found in policies from periods of the country's history, from colonial subjugation, apartheid dispossession, to the post-apartheid period. Racial and gender discrimination, the migrant labour system, the destruction of family life, vast income inequalities, and extreme violence have all formed part of South Africa's troubled past, and all have inexorably affected health and health services. 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."

Although SA is considered a middle-income country in terms of its economy, it has health outcomes that are worse than those in many lower income countries. Around a third of disability-adjusted life years (DALYS) are due to HIV/AIDS, with interpersonal violence contributing 7% and tuberculosis 4%. While murders reported to police in 2008 were 40% below 1996 levels, rapes only fell 6% in the same period.

In 2005, less than 15% of the population were members of private sector medical schemes, yet 46% of all health-care expenditure is attributable to these schemes. A further 21% of the population use the private sector on an out-of-pocket basis mainly for primary level care, but is generally dependent on the public sector for hospital care. The remaining 64% of the population is entirely dependent on the public sector for all their health-care services. The authors conclude: "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. Pivotal facets of primary health care are not in place and there is a substantial human resources crisis facing the health sector. The HIV epidemic has contributed to and accelerated these challenges. All of these factors need to be addressed by the new government if health is to be improved and the Millennium Development Goals achieved in South Africa."
Professor Hoosen Coovadia, Director: HIV Management, University of the Witwatersrand, Johannesburg; and Victor Daitz Professor of HIV/AIDS Research, University of Kwazulu-Natal, Durban, SA T) +27 31 261 8840 E)

Alternative contacts: Diane McIntyre +27 21 448 8152, +27 82 496 2345 ; Peter Barron +27 21 447 3441; David Sanders +27 21 959 2132

Full paper 1:


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