TALKING POINTS

South Africa used to have a good public healthcare system. What has changed?

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In 1994 the new ANC led government of South Africa inherited unequal and fractured health departments. At the administrative level, the apartheid state prioritised the service and maintenance of facilities designed for the use of white South Africans at the expense of those designed for the rest of the population.

In addition to being unfair, the pre-1994 government was inefficient and cumbersome. Health budgets were allocated to four provinces, four ‘independent states’ (Bophuthatswana, Transkei, Venda and Ciskei and five ‘self-governing homeland’ governments. Structurally, the apartheid homeland policy added ten additional state departments of health at the first tier of government. Different race groups were allocated a range of levels of funding.

How did the health spend per capital vary between provinces and homelands?

Per capita expenditure figures varied greatly. In 1983/84 for example, expenditure on curative care in ‘white’ South Africa ranged from a high of R127 in the Cape Province to a low of R79 in the Orange Free State; in the homelands the per capita expenditure on all care was lower, ranging from R45 in the Ciskei to R16 in Lebowa.[i]

So the title of this article is wrong. It would be more accurate to say that South Africa’s health system provided good, well funded health services for about 10 million of approximately 40 million people, and under-funded services for all other groups. 

How did the new government try to restore the balance?
Since 1994, the ANC led government has introduced a number of health policies to counter the skewed apartheid era provision of services. The main initiatives were the following:

  • The creation of a single Department of Health, designed to provide health services to all population groups.
  • A shift from relatively well provided services in urban areas to the provision of services in the rural areas.
  • A shift from a curative, hospital centric health system, to a preventative, primary health based system. This has meant cutting the budgets for hospitals and increasing the budgets for primary clinics.
  • The provision of free public sector services to all children under the age of 6 as well as pregnant women.

Were these measures successful?
However, the new Department of Health was not provided with the money to achieve these objectives. Real (after inflation) per capita public spending on health care declined after 1996 and only regained 1996 levels in 2005. The net effect was a serious shrinkage in available health resources in the public sector over a ten year period.

At the same time, this period saw a considerable increase in the demand for health services because of the HIV/ Aids epidemic. The table below shows that the Department of Health estimated that about 850 000 people (approx 2.1% of the total population) were HIV positive. This compares with 5.077 million (approx 9.8%) of the current population.

The table below also shows that the doctor: population ratio has deteriorated from an estimated 6.7 medical practitioners per 1000 people to 4.5 medical practitioners per 1000 people, using population figures from the 2011 census.

But one of the most striking statistics is the change in the ratio of the number of hospital beds per 1000 people between 1986 and 2011.

As we mentioned in last month’s article, in 1986, 95% of almost all hospital beds (117 842 out of 123 967) were in the public sector. By 1998, there were about 122 542 hospital beds in South Africa, of which about 20 908 were private sector beds. But by 2013 the picture had changed dramatically; the total number of beds had declined to 84 920, with 47 051 public sector beds and 37 869 private sector beds. .

These figures are starker when measured in terms of beds per population, because the absolute number of beds in the public sector has declined while the population has increased. In 1986, the hospital bed: population ratio for white South Africans was 8.2 beds for a 1000 people, for black people within South Africa it was 4.2 to 1000 and the average ratio for black people in the homelands was 2.4 to 1000.[ii]

The current ratio, based on figures released in the National Health Care Facilities Baseline Audit (2013) and the 2011 census population is 47 051 beds/ 51.77 million people which works out at 0.9 beds to 1000 people in the public sector across South Africa. Including the private sector beds there are 1.6 beds per 1000 population.

So where does that leave us now?
South Africa simply does not have enough hospital beds for our ‘normal’, let alone those extra needs that have been introduced by the current burden of disease. Even including the private sector beds, our beds to population ratio is less than Brazil (2.3 beds per 1000) China (4.2 per 1000), but more than India (0.9 per 1000).

At the same time, the Department of Health is committed to its focus on a preventative health policy for South Africa and it is unlikely that our bed to population ratio will improve in the near future. There are no easy solutions to the current situation which is characterised by increased demand for healthcare services and reduced budgets. 

For more on this see www.oecd.org/southafrica

 1994 (or nearest in brackets)2014 (or nearest in brackets)Source
Population of South Africa 40.58 million (1996 census) 51.77 million (2011 census) Statistics SA
www.Statsa.gov.za
Health expenditure as a percentage of Gross National Product Total = 6.19% Public = 3.02%, Private 3.16% Total = 8.5% Public = 4%, Private = 4.5% National Treasury, OECD Health Data
www.treasury.gov.za
www.oecd.org
Medically insured population of South Africa 6.58 million (about 16.21%) 8.67 million (about 16.74%) Council for Medical Schemes Annual Reports
www.medicalschemes.com
No medical insurance 34 million 43.2 million Calculated from Council for Medical Schemes statistics.
Public health expenditure as a proportion of total government expenditure 9.6% (1995) 11.9% (2010) National Treasury
www.treasury.gov.za
Number of doctors general practitioners and medical specialists in South Africa divided by the number of people in South Africa 27 551 (1998) Using the 1996 census figures there are 6.7 medical practitioners per 1000 people. 23 408 (2011). Using the 2011 census figures there are 4.5 medical practitioners per 1000 people. 1998 figures sourced from Health and Healthcare in South Africa, 2011 figures sourced from the South African Medical Journal 101: 523 -528
Percentage of registered nurses older than 50 years. 36% (2005) 47% (2012) Data from 2005 and 2012 from the South African Nurses Council website
Average longevity M = 57.36 (1994)
F = 64.76
M =51.42 (2010)
F = 52.78
World Bank statistics
www.tradingeconomics.com
Number of people living with HIV/ Aids 850 000: Approx 2.1% of the total population. 5.077 million: Approx 9.8% of the total population Department of Health estimates for 1995 and 2012.
www.doh.gov.za
Number of hospital beds in South Africa

In 1996, the estimated number of private hospital beds was 5 000, and the number of public sector beds was 115 000.

The total number of beds was therefore 120 000.

According to the National Health Care Facilities Baseline Audit National Summary Report, February 2013 there were 47 051 public sector beds in South Africa. A range of sources estimates the number of private beds at 37 869. In total there are 84 920 hospital beds.

The 1996 figures are sourced from the Review of competition in the South African Health System, produced for the Competition.

Commission, by Alex vd Heever . The 2013 figures are sourced from the National Health Care Facilities Baseline Audit National Summary Report, February 2013.

Life expectancy at birth for South African males: 1992 - 2010

Source: http://www.tradingeconomics.com/south-africa/life-expectancy-at-birth-male-years-wb-data.html

Life expectancy at birth for South African females: 1992 - 2010

Source : http://www.tradingeconomics.com/south-africa/life-expectancy-at-birth-female-years-wb-data.html

Under 5 mortality rate : 1995 to 2010

Source : http://www.tradingeconomics.com/south-africa/mortality-rate-under-5-per-1-000-wb-data.html

[i] Health and Healthcare in South Africa, edited by HCJ van Rensburg, published by Van Schaik, 2011. Pg 89
[ii] Ditto

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