Feature story

Bridging the health gap in South Africa

09 November 2010

A longer version of this article appeared in the November Bulletin of the World Health Organization   

Credit: UNAIDS

When she was four years old, Thando* was taken to a public hospital in Johannesburg for HIV treatment. “I first saw her in 1998 with advanced disease and her CD4 count was less than 50,” says Ashraf Coovadia, a paediatrician at the Rahima Moosa Mother and Child Hospital. “In 1999 we managed to get her antiretrovirals (ARVs) through a research project.”

Prior to 2003, ARVs were not available in the public health system in South Africa, the country with the highest number of people with HIV in the world. While private patients could get access to the life-saving drugs and buy their survival, many patients in the public sector did not survive.

It is this stark public–private divide that the South African government hopes its proposed National Health Insurance (NHI) scheme will tackle by providing universal access to health care “based on need rather than ability to pay.”

The starting point for the NHI is to close the increasing gap between the rich and the poor

Dr Aaron Motsoaledi, Minister of Health of South Africa

Thando was lucky to get therapy in time and this “lovely teenager”, raised by her aunt, is the longest attending patient at the hospital’s paediatric clinic. “Prior to the rollout, we had a handful of children accessing ARVs, less than 5%. Now the majority who need it are on ARVs and doing well,” says Prof Coovadia.

Access to treatment for HIV has expanded dramatically in the past decade and, since the 1994 democratic elections, access to health services in general have improved for poorer South Africans. However, some believe that the standard of care in the public sector has been steadily deteriorating.

“South Africa has had difficulty post 1994 in grappling with the HIV epidemic—that was a real curveball,” says Helen Schneider, Chief Researcher at the University of Cape Town’s (UCT) Centre for Infectious Diseases Epidemiology and Research.

South Africa has had difficulty post 1994 in grappling with the HIV epidemic—that was a real curveball

Helen Schneider, Chief Researcher, Centre for Infectious Diseases Epidemiology and Research.

Health Minister Aaron Motsoaledi told the Bulletin: “the starting point for the NHI is to close the increasing gap between the rich and the poor. If I am sick, I get the best care. If people are unemployed, they can forget it.” Dr Motsoaledi describes the existing health-care system as “very expensive, destructive, unaffordable and not sustainable.”

In September 2010, the ruling African National Congress (ANC) released its current proposals for the NHI for wide consultation. According to Zweli Mkhize, chairman of the ANC’s health committee, the scheme, which aims to provide universal coverage for all South Africans, is expected to cost an extra R11 billion on top of the R117 billion in the government’s health budget for 2012. Taxation to pay for this compulsory medical insurance scheme is expected to start in 2012, with a plan to phase it in over 14 years.

A private economic consultancy, Econex, has published an extensive critique of the proposals, teasing out some of the implementation challenges, chief among them the enormous anticipated cost of the system as currently conceptualized.

And cost models produced for the Congress of South African Trade Unions, which strongly supports the introduction of NHI, suggest an additional funding requirement of around R189 billion, before administrative savings.

The NHI would also introduce new dimensions to the South African health financing system, notably the possibility of using public resources through strategic purchasing of services for the population. According to Di McIntyre, a professor from UCT’s Health Economics Unit, this would ensure that “everyone will be able to access health services on the basis of their need for care and not on the basis of their ability to pay.”

*Thando’s name has been changed.