/ 5 February 2024

Healthcare in South Africa after 30 years of democracy: The good, the bad and the ugly

Burden: Medical staff at Tembisa Hospital on the East Rand work hard with few resources to assist the many people seeking healthcare. (Guillem Sartorio/Getty Images)

As South Africa enters its 30th year of democracy, many will be reflecting on how much has changed. The country has faced and continues to face serious problems, not least the triple threat of poverty, unemployment and inequality. To understand where we are, it must be placed in the context of where we were. This is no less true for healthcare than it is for other integral aspects of living with dignity. 

White South Africans, or more accurately, wealthy white South Africans, have enjoyed the highest quality healthcare possible through the private sector since the 19th century. Medical schemes were introduced in 1960 to meet the healthcare demands of white mine workers — plans that were exclusive to the white population until the late 1970s. Of course, few black people could join because of the financial cost and the economically crippling effects of apartheid; poverty that largely continues to this day.

During apartheid, South Africa was divided into four “independent” homelands — Bophuthatswana, Ciskei, Transkei and Venda — and six “self-governing territories” — Gazankulu, KaNgwane, KwaNdebele, KwaZulu, Lebowa and Qwaqwa. Each of these territories operated with its own health department, leading to a staggering 400 local authorities managing separate health services. This decentralised approach resulted in poor coordination, fostering significant disparities in healthcare provision. 

Post-apartheid, the challenge was to integrate this disjointed structure into a more cohesive healthcare system. The solution came in the form of nine provincial health services absorbing the responsibilities. The 1994 government headed by Nelson Mandela made valiant efforts to address the health disparity between rich and poor. The ANC of the time introduced housing programmes, reformed the education system and introduced a clinic building programme to increase the number of primary healthcare facilities in disadvantaged areas.

Probably the greatest public health crisis in post-apartheid South Africa has been the HIV/Aids epidemic. The epidemic began in the late 1980s but worsened post-1994. Former president Thabo Mbeki questioned the scientific consensus that HIV caused Aids, and his administration delayed the launch of an antiretroviral programme and restricted the use of antiretroviral drugs. It’s estimated that these policies cost more than 330 000 premature deaths from HIV/Aids between 2000 and 2005. But the government performed a remarkable turnaround. Since 2004, the Antiretroviral Therapy (ART) programme has evolved to become the largest worldwide, with about 5.8 million people on treatment. This is a fabulous achievement — one that has saved countless lives. 

Although there are now as many black people using the private healthcare system as white people (15.8% of the population now use it), a stark inequality between rich and poor remains. Despite the healthcare reforms implemented since 1994, the intended improvement in public healthcare accessibility and quality has been slow to materialise, particularly in the former homelands. These regions continue to bear the brunt of historical neglect, grappling with persistently subpar health services. It remains almost impossible for many of those living in rural areas to access high quality healthcare facilities, and a walk through almost any public hospital in the country would horrify those used to the private sector. Why is this the case?

It doesn’t help that so few South Africans pay taxes. In a country with a population of 60 million, only 6.4 million tax returns were filed in 2021. And 52% of the country’s taxable income is retrieved from just over a million taxpayers. That, of course, speaks largely to the country’s income inequality. 

The South African Revenue Service brought in R1.56 trillion after the 2022 collections, providing a health budget of R60.1 billion for 2023-24. For comparison, in the 2022-23 financial year, the United Kingdom’s department of health and social care budget was £171.8 billion — that’s R4 050 billion; more than 65 times the amount South Africa gets to spend. Yet, the UK’s National Health Service (NHS) is increasingly struggling to keep up with demand. Waiting times are through the roof, and patients struggle to get appointments with their local general practitioners.

To add to the budgetary problem, the South African healthcare sector is plagued with corruption. From the R150 million Digital Vibes scandal (implicating the former minister of health, Zweli Mkhize) to the R500 000 spent on skinny jeans by Tembisa Hospital. The budget is already incredibly low. Corruption just adds insult to injury. 

The small tax base and corruption inevitably have a material effect. In 2023, at least 1 000 qualified doctors in South Africa were jobless, with no prospect of employment. According to the South African Medical Association Trade Union, 800 positions remain unfilled because of budgetary constraints.

So, what’s next? The ANC will proudly tell you it’s the National Health Insurance (NHI), a publicly funded medical scheme that we will all be members of. Perhaps it will come in, in some guise, but as it stands the bill is unfeasible. It prohibits anyone from choosing to pay for their own private healthcare, leaving the middle class in the healthcare lottery. No guarantee of private healthcare, despite providing all the funding. There could be a mass exodus of taxpayers, for whom guaranteed quality healthcare is a dealbreaker. Reducing the tax base even further should be the last thing the government wants. 

More to the point, though, a high level of healthcare for everyone is unaffordable as it stands. Should all current medical aid contributions be added to the existing health budget, that budget would roughly double. But that’s still R120 billion, which is R3 930 billion less than the UK’s failing NHS has to spend on a similar-sized population. 

It would be wrong to ignore all the progress that’s been made since 1994. Democracy has yielded some wonderful improvements in healthcare for many marginalised people. The ART programme has been a success, and many black people who previously would have had no chance of receiving quality healthcare, now can. But the healthcare system is still failing the majority of South Africans, and NHI is not the solution. Once again, the triple threat of poverty, inequality, and unemployment (and those responsible for that) is largely to blame. Until South Africa can radically improve its economy, making it more inclusive and business-friendly to drive up GDP and tax revenue, it’s very difficult to see how the country can provide the constitutionally guaranteed quality healthcare for all. 

Professor Benjamin Smart is a director of the Centre for Philosophy of Epidemiology, Medicine and Public Health at the University of Johannesburg.