South Africa’s healthcare system is gradually emerging from the challenges posed by the Covid-19 pandemic. In the fight against the virus, the healthcare system exhibited a number of successes, however there remain deep flaws that are yet to be addressed. The shortcomings in the government’s response to the pandemic were products of the persistent challenges that the country’s healthcare system has faced for decades. With the new ‘National Health Insurance’ scheme in the pipeline – a medical aid fund aiming to introduce universal health coverage across the country – the South African government must take into account the needs and concerns of its people, the lessons drawn from Covid-19, as well as the broader historical-structural issues that continue to plague the country’s healthcare system.

South Africa’s Healthcare Landscape

South Africa’s constitution grants every citizen the right to healthcare through the private or public sector. Public healthcare is available to all citizens for free, without the need for health insurance. It is largely funded by the National Revenue Fund, which collects payments made to local, provincial, and federal governments. The funds are then distributed from federal to sub-national authorities, who enjoy substantial independence over the allocation of resources, depending on local priorities and necessities. 

However, the constitution’s provisions are often not reflected in practice, particularly due to the gap between the public and private sectors. The public sector provides healthcare to 80-85 per cent of the population and accounts for approximately 48 per cent of total healthcare expenditure, while the private sector provides healthcare to the remaining 15-20 per cent of the population and attracts approximately 50 per cent of total government healthcare spending. The remaining 2 per cent is covered by NGOs. Just under 80 per cent of doctors work privately, where they earn higher salaries, leaving only 20 per cent of doctors in the public sector to serve the vast majority of the South African population. This presents a clear disjuncture between the public and private health sector, with major differences emerging in terms of funding, resources, and support.

The public/private healthcare divide often tracks racial lines, raising questions around the legacy of colonialism and apartheid in South Africa’s healthcare system. In the 1986-1987 financial year, just before health services were desegregated in 1988, South Africa’s spending in the former white provinces amounted to $9.30 per capita, compared with $3 per capita in former majority-black areas. Today, access to quality healthcare remains unequal and often contingent on individuals’ ability to pay for private care or live in urban centres. Public healthcare is not allocated based on need, but rather determined by each province’s relative share of the population, thus ignoring factors such as geographic expanse, as well as demographic and implementation specificities.

This legacy of racial-economic inequality is all the more alarming because diseases, such as Covid-19 and HIV/AIDS, often disproportionately affect lower-income populations. South Africa hosts the largest HIV/AIDS epidemic in the world; around 8 million South Africans are currently affected, accounting for 17-20 per cent of global cases. At first, the government’s denial of the virus’s existence resulted in a slow response; however, between 1999 and 2005, spending on HIV/AIDS increased at an average rate of 48.2 per cent annually. Since 1990, the number of people living with HIV/AIDS has continued to increase, but the mortality rate from the virus has been gradually declining since the mid-2000s, thanks to the development and diffusion of antiretroviral treatment.

Additionally, South Africa still suffers from a relatively high infant mortality rate, concentrated in remote and poorer areas. In 2018 alone, an estimated 43,000 children under five years of age died in South Africa. In contrast with its African counterparts, South Africa exhibits a relatively high healthcare expenditure, amounting to just over 9 per cent of GDP in 2019, a level of spending surpassed only by Lesotho.

Higher spending on healthcare, however, has not yielded proportional results. South Africa suffers from similar levels of inadequate infrastructure, social inequalities and disease burden as other countries in southern Africa. Yet healthcare systems in Rwanda and Kenya have often performed better and at lower costs. Contrary to South Africa, almost half of Kenya’s poor utilise private healthcare. Both Kenya and Uganda have used mobile health more extensively than South Africa to provide healthcare to low-income communities. In the South African market, there is thus a great amount of space for digital health-focused NGOs and startups to step in and make an impact. South Africa could also benefit from the adaptation and incorporation of policies that have proven successful in other African countries.

In 2012, the South African government presented plans to implement a national health insurance scheme over the following 14 years. This health financing scheme, or more precisely fund, is designed to cover the costs of healthcare services for all South Africans, thus aiming to move the country towards universal health coverage (UHC) and to improve the quality of, and access to care. In June 2023, lawmakers approved the NHI and in December, the National Council of Provinces (NCOP) voted in favour of its implementation, with opposition voiced only from the Western Cape province. It must now be signed into law by President Ramaphosa. The NHI broadly aims to address social imbalances in the world’s most unequal society. It envisages the creation of a fund that pools public and private resources, ensuring equal healthcare access and outcomes for all South Africans, regardless of socioeconomic status. The NHI will be funded through public contributions, likely in the form of income-proportional taxes. The policy could deliver various benefits: not only could it lower healthcare costs for South Africans, but also ‘standardise’ salaries and expectations of all healthcare providers. The NHI could also help eliminate health-related barriers to education, drive economic growth by building a healthier workforce, and improve social security, as access to healthcare and education may reduce crime and welfare dependency. Additionally, the NHI could open up opportunities for public-private healthcare collaboration.

Despite widespread support for the NHI and the potential advantages of universal healthcare, as seen in other middle-income countries like Brazil and Thailand, some have raised significant concerns, particularly with regards to the NHI’s implementation. First, the NHI’s funding remains a key point of contention, as its estimated cost runs over $27 billion annually. Critics point to South Africa’s weak tax base, due to the high number of people working in the informal sector, as well as slow economic growth, as evidence for impending financial challenges and increased tax burden for citizens. These worries are heightened by recurring allegations of governmental corruption and poor administrative oversight. Second, private healthcare providers have expressed concerns about the uncertainty regarding their role in this new system, highlighting the danger of job losses should the private sector not be effectively integrated. Medical practitioners may also choose to leave South Africa in search of better paid jobs, contributing to a resource shortage in the public sector. Third, critics fear that the NHI may result in lower quality healthcare, as the government does not have enough resources to meet the needs of all South Africans. Fourth, the proposed NHI framework is unclear on several issues, including the range of treatments to be covered and the rate of reimbursement. The South African government will therefore need to address the lack of trust in the NHI’s potential by outlining a concrete roadmap, evidencing the scheme’s ability to offer reliable as well as inclusive access to healthcare, and dispelling views of the proposal as a mere idealistic utopia.

Successes in South African Healthcare

In recent years, and particularly in response to Covid-19, South Africa’s healthcare system has had notable success.

1. Since the mid-1990s, the country has reduced maternal and under-5 mortality rates, as well as death rates from infectious diseases. It has also expanded immunisation programs, which were, however, paused during the Covid-19 pandemic to comply with national lockdowns.

2. Many healthcare organisations have created innovation teams and digital strategies to follow developments in AI, telemedicine, and digitisation. Both the public and private sector have also improved data analytics capabilities to track shifts in healthcare needs and resource availability in order to identify key risks and opportunities. These measures have, for instance, contributed to promising advances in the use of nanotechnology for cancer treatment. The Covid-19 pandemic further encouraged South Africa’s healthcare sector to gradually, but comprehensively embrace digital technologies, not just for data analytics, but also to support the accelerated adoption of virtual healthcare, which has helped reduce pressures on facilities and minimise inequalities.

3. Macro- and micro-level healthcare initiatives have jointly widened access to care. At the national level, the ‘Transnet Phelophepa Health Trains’ have helped treat 200,000 patients annually by taking mobile clinics into rural areas through South Africa’s railway system. At the local level, in 2013, a Cape Town resident founded the ‘Iyeza Express’ bicycle courier service, which employs local youth to collect medication from public health facilities and deliver them to people’s homes, particularly in the city’s poorer districts. In the same year, to reduce time spent queuing at health facilities, a Johannesburg local created ‘Pelebox Smart Lockers’, which sends a PIN to patients’ mobile phones to open lockers containing prescribed medications. These initiatives have boosted the efficiency of South Africa’s healthcare system.

Challenges in South African Healthcare

Despite noteworthy successes, the South African healthcare system has encountered a number of challenges that have impacted its performance. These challenges have fed many of the criticisms that are now directed against the proposed NHI.

1. Most importantly, South Africa’s healthcare system has suffered from a lack of resources and personnel, particularly when considering the country’s large population and ‘quadruple disease burden’ (HIV/AIDS, communicable diseases, non-communicable diseases like diabetes, and violence and injuries). The Covid-19 pandemic highlighted that the needs of South Africans exceed the country’s healthcare system’s human, material, and financial capacities. Throughout the pandemic, underfunded and understaffed hospitals handled insufficient and outdated equipment, while following constantly changing protocols. Long work hours, extended waiting times, and overcrowded health facilities became the norm, particularly in rural areas. South Africa’s weak primary healthcare system, the lack of political will, and the government’s underestimation of Covid-19’s severity meant that the virus was not thwarted in its early stages. The mismanagement of the pandemic also led to the stigmatisation of communities with high Covid-19 cases, increased episodes of gender-based violence, and social discrimination in the distribution of food aid.

2. In part resulting from the country’s limited resources and staff, economic, racial, and geographic inequalities remain a keystone of South Africa’s healthcare system. The private and public sectors, as well as urban and rural localities, display massive healthcare imbalances, in terms of quality and access. In regards to the former, South Africa’s private clinics charge fees that are commensurate with those of significantly wealthier nations, due to the lack of pricing regulations. This practice has made private healthcare inaccessible for the majority of South Africans. During the pandemic, access to testing and vaccines was clearly determined by individuals’ ability to pay, with lower-income groups left behind. This outcome was, at least partially, a result of the government’s insufficient spending on public healthcare. This policy does not follow from an established norm of obtaining healthcare from the private sector, as in the United States; rather, it represents an extension of South Africa’s apartheid-era policies that cater to a small, rich section of the population. 

   With regards to the rural-urban gap, residents of major urban centres have a significantly higher chance of receiving treatment than people living in rural areas, due to the disproportionate concentration of health facilities in large cities. Apartheid-era urban planning has meant that health clinics remain inaccessible to the majority of South Africans, for financial and practical reasons. Additionally, the marked disparity in skill between urban and rural regions contributes to persistent inequalities in terms of the quality and outcomes of healthcare. This inequality has nurtured a low ‘acceptance’ of the national public healthcare system among many South Africans, with patients being not only unable, but unwilling to seek treatment due to, for instance, perceptions of (in)efficiency, language barriers, and ethnic and religious under-representation.

   However, micro-level initiatives have helped redress skill shortages in rural areas. The ‘Umthombo Youth Development Foundation’, for example, provides medical scholarships to students from remote areas. The aim is that these students later return to their home communities to offer healthcare that is perceived as more trustworthy, credible, and thus more effective. Here, healthcare startups and community or national-level NGOs can thus play a key role: they can first focus on assisting the expansion of existing programs, including the ‘Iyeza Express’ and the initiative developed by the ‘Umthombo Youth Development Foundation’, both locally and nationally. Second, given the South African government’s limited resources, these organisations can prioritise providing financial and logistical support for the development of new initiatives, particularly those geared towards improving remote areas’ access to quality healthcare and those encouraging community-based health education and university-level medical education, in an attempt to raise health awareness and redress the country’s shortage of health personnel.

3. Rampant corruption, and the lack of enforcement and accountability mechanisms to counter it, pose a major barrier to progress in South Africa’s healthcare system. Private healthcare providers, for example, reportedly submit inflated or forged claims of treatment to private health insurance schemes to maximise their revenue. The difficult response to Covid-19 was exacerbated by widespread corruption, abuse of funds, and the syphoning of scarce resources away from rural clinics.

Looking Ahead

In light of these challenges, South Africa’s healthcare sector faces a set of key risks in years to come. First, persistent resource shortages and the country’s dependence on imports from countries such as India and China will continue to dictate the trajectory of its healthcare system. Without substantial investment in the domestic manufacturing industry, progress in healthcare provision will be constrained by a resource bottleneck and may also become affected by foreign interests. Nevertheless, like many other countries in Africa, South Africa is well-positioned for the development of innovative healthcare practices and technologies that address constraints such as resource scarcity. Second, in view of the NHI’s implementation, talent retention will remain a key challenge, as skilled healthcare workers, particularly from the private sector, may choose to leave South Africa in search of more profitable opportunities. Third, while technology will be central to the expansion of care in South Africa, it will also increase the country’s vulnerability to cyberattacks, which it is not yet equipped to counter. There is thus a need for increased private-public cooperation to develop stronger national cybersecurity infrastructure.

Despite such risks, South Africa is now at a critical juncture, navigating the aftermath of a devastating pandemic, nearing the deadline for the NHI’s implementation as well as the 2024 general elections, and situated amidst a global technological revolution. The country faces a pivotal opportunity to reform its healthcare system in line with the lessons learnt from past failures:

1. In the first place, as highlighted by the country’s experiences with HIV/AIDS and Covid-19, South Africa should invest in preventive measures, including R&D and risk outlook units, to better monitor and predict outbreaks of infectious diseases.

2. Second, the incoming South African government must strengthen its leadership before implementing the NHI, for example by facilitating meaningful public-private partnerships and by fostering communication between key players. At present, different parts of the public system are managed by different government units, while private doctors operate in isolation from one another. South African leadership should instead promote linkages, or even integrate, the private and public sectors, as the former generally has more resources than necessary to treat its patients and as such, can help fill major gaps in the public sector. 

   To enhance its credibility and legitimacy, the incoming government must also cultivate public trust in the healthcare system and the NHI, if it decides to persevere with its implementation. It must clarify the NHI’s provisions, encourage transparency, and promote accountability to address corruption. It can do so by making performance data publicly available to encourage improvements on the provider side, while keeping clients informed on relevant developments. It can also establish city-wide integrated management teams to replace the current fragmented system and to redirect financial oversight from the national to the city level to reduce the risk of corruption, a model that proved successful in the Chinese province of Sanming. 

   The government could also develop education initiatives to raise awareness about the current medical system and the potential benefits of universal healthcare, to enhance support for the NHI. Additionally, framing better healthcare outcomes as beneficial for South Africa’s long-term economic growth can encourage wider domestic support as well as foreign direct investment.

3. Third, and more broadly, the government will have to ensure that the transition towards universal healthcare involves all relevant stakeholders in the public and private sector, at the local and national level, in and beyond South Africa. It must carefully balance actors’ competing interests and concerns before the NHI is implemented. In particular, South Africa should capitalise on the opportunities offered by new and existing international partnerships to unlock the healthcare sector’s full potential. Although South Africa is one of the least aid-dependent states in Africa, international donors and financiers can provide critical funding and resources, support capacity-building, share best practices, and catalyse the wider delivery of healthcare services. At the same time, South African leadership should support micro-level initiatives like the Iyeza Express, which will prove valuable to reach the most vulnerable and better respond to the needs of remote communities.

4. Fourth, South Africa can benefit from adapting and adopting successful policies from fellow African countries and other middle-income counterparts worldwide. For example, Malawi’s toll-free health hotline represents one of the many strategies that South Africa could implement to provide communities with reliable access to virtual care and remove the need to travel long distances to the nearest facilities. South Africa can also learn from Mexico’s and India’s experiences with universal healthcare, which have respectively highlighted the benefits of effective regional governance to complement national leadership, and the importance of human and physical infrastructure to drive meaningful change. 

   Perhaps most importantly, Rwanda’s successful universal healthcare policies can provide a useful model for South Africa, as the two countries lack extensive public resources and must overcome a legacy of conflict and inequality. Rwanda’s healthcare system fundamentally rests on a community-based health insurance scheme, known as ‘Mutuelles de Santé’, whereby residents of particular areas contribute to a local health fund, supported by the state and international agencies, and which they draw from when necessary. The poorest do not pay anything, while richer individuals may be responsible for co-payments. To sustain this system, the Rwandan government has supported the deployment of community health workers to the country’s 15,000 rural villages, as well as the establishment of health posts in remote areas to cut patients’ average walking time to care facilities in half, from 47 minutes in 2020 to 24 minutes in 2024. These initiatives have helped close gaps in access to healthcare and have built a workforce that is more receptive to its population’s healthcare needs.

The incoming South African government must ultimately focus on balancing the goal of achieving universal healthcare with the quality of care itself, as well as with economic and political realities. It should harness contemporary digital advances, utilise lessons learnt thus far from its experiences with HIV/AIDS and Covid-19, take on board popular concerns with the proposed NHI, and approach healthcare as a human right.