country briefing: South Africa – health

by admin on September 1, 2010

Team: Eric Berger, Tara Thomas, Heather Vital, and Anne Wang
for GHD Lab, February 22, 2011
Instructor: Professor Anjali Sastry; TA: Lilian Tse

Health Indicators, Prevalence of Diseases, Other Measures

South Africa’s health landscape is extraordinarily dynamic especially due to the ravaging effects of HIV.  In 2007, the WHO estimated that 17.64% of the population ages 15-49 was infected.  This infection rate has taken its toll on the average life expectancy at birth which hovers at 53.4 years (2005 estimate). There is also a high burden of tuberculosis, cardiovascular diseases, and violence and road traffic accident associated injuries.  In addition, the maternal mortality ratio is approximately 15/10000 live births and child mortality rate of about 55/1000 live births (2005).

South African Demographic Statistics
Total population 48,282,000
Gross national income per capita (PPP international $) 8,900
Life expectancy at birth m/f (years) 50/53
Healthy life expectancy at birth m/f (years, 2003) 43/45
Probability of dying under five (per 1 000 live births) 69
Probability of dying between 15 and 60 years m/f (per 1 000 population) 598/531
Total expenditure on health per capita (Intl $, 2006) 869
Total expenditure on health as % of GDP (2006) 8.6

Source: WHO, Country Cooperation Strategy at a glance: South Africa (2006)

Health System Overview

South Africa’s two-tiered health system consists of a large public sector and a small but fast-growing private sector. These systems rely heavily on the country’s human resources and infrastructure. There are some human resources but shortages still exist.  Similarly, current distribution infrastructure favors urban areas with greater variability in rural health access. The following table summarizes the principal accomplishments and shortcomings of the past 15 years:

Accomplishments Shortcomings
Legislation and gazetted policy 

1.       Free primary health care

2.       Essential drugs program

3.       Choice on termination of pregnancy

4.       Anti‐tobacco legislation

5.       Community service for graduating health professionals

Better health systems management

1.       Greater parity in district expenditure

2.       Clinic expansion and improvement

3.       Hospital revitalization program

4.       Improved immunization program

5.       Improved malaria control

Insufficient prevention and control of epidemics 

1.       Limited effort to curtail HIV/AIDS

2.       Emergence of MDR/TB and XDR/TB

3.       Lack of attention to the epidemic of alcohol abuse

Persistently skewed allocation of resources between public & private sectors

1.       Inequitable spending patterns compared to health needs

2.       Insufficient health professionals in public sector

Weaknesses in health systems management

1.       Poor quality of care in key program

2.       Operational inefficiencies

3.       Insufficient delegation of authority

4.       Persistently low health worker morale

5.       Insufficient leadership and innovation

Source: Harrison, David (2009) An Overview of Health and Health care in South Africa 1994 – 2010: Priorities, Progress and Prospects for New Gains

Health care varies from the most basic primary health care, offered free by the state, to highly specialised hi-tech health services available in the private sector for those who can afford it. The public sector is under-resourced and over-used, while the mushrooming private sector, run largely on commercial lines, caters to middle- and high-income earners who tend to be members of medical schemes (18% of the population), and to foreigners looking for top-quality surgical procedures at relatively affordable prices. The private sector also attracts most of the country’s health professionals.

Current health issues in the country

The country is making efforts at addressing the health needs of the population.  Access to services such as antenatal care is about 94%. Skilled attendance at birth is 84%. Prevention of Mother to Child Transmission (PMTCT) is available in 90% of facilities with a 66% uptake in 2007. The treatment protocol for PMTCT has been improved to include dual therapy. About 80% of the population has access to the essential package of interventions within an hour of a health facility based on any mode of transport available. Health development partners are also supporting the sector in its programs.   The orientations and strategic agenda mean that in South Africa, HIV/AIDS, tuberculosis, malaria, maternal, child and adolescent health and road traffic accidents will be priority.

Access to care, health equity

There are still significant inequities in the South African health system.  For example, although the state contributes about 40% of all expenditure on health, the public health sector is under pressure to deliver services to about 80% of the population. Despite this, most resources are concentrated in the private health sector, which sees to the health needs of the remaining 20% of the population.

Public Health Expenditure: Public health consumes around 11% of the government’s total budget, which is allocated and spent by the nine provinces. How these resources are allocated, and the standard of health care delivered, varies from province to province. With less resources and more poor people, cash-strapped provinces like the Eastern Cape face greater health challenges than wealthier provinces like Gauteng and the Western Cape.

Clinical Care: The number of private hospitals and clinics continues to grow. Four years ago there were 161 private hospitals, with 142 of these in urban areas. Now there are 200. The mining industry also provides its own hospitals, and has 60 hospitals and clinics around the country.  Most health professionals, except nurses, work in private hospitals. With the public sector’s shift in emphasis from acute to primary health care in recent years, private hospitals have begun to take over many tertiary and specialist health services.

Pharmaceutical Access: Drug expenditure per person varies widely between the sectors with far higher expenditure in the private sector. For example, in 2000 about R8.25 B was spent on drugs in South Africa.  However, only 24% of this amount was spent by the state.  In fact, an average of R800.29 per person was spent in the private sector.

Impact of public health/health system issues on enterprises’ roles in delivering health care

Strong socioeconomic development: Compared to much of the rest of continent, South Africa is well positioned financially and continues to be a key market in the region.  As a result, funding, including for health is more readily available.

Active partner organizations involvement: There are over 25 bilateral, multilateral and international development partners for health sector development in South Africa. The main ones include:

North American Agencies European Agencies Asia-Pacific Agencies Multi-lateral Organization
United States Agency for International Development (USAID) Norwegian Agency for Development Cooperation (NORAD) Australian Agency for International Development (AusAID) United Nations Agencies and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)
United States Government (USG) through PEPFAR German Technical Cooperation Agency (GTZ) Japan International Cooperation Agency (JICA) International Organization for Migration (IOM)
Cuba Department for International Development (DFID-UK) Country Support: New Zealand Southern African Development Community (SADC)
The European Commission New Partnership for Africa’s Development (NEPAD)
UK Department for International Development (DFID) 15 UN Agencies
Country Support: Belgium, Greece, Finland, and Italy IMF/World Bank

Source: WHO, Country Cooperation Strategy at a glance: South Africa (2006)

These organizations have made and continue to make significant investments in expand South Africa’s health system.

Well developed infrastructure: Comparatively to many of the other countries on the continent, South Africa is relatively well positioned from an infrastructure standpoint to meet many of its population’s health needs.  This limits one of the often restrictive factors in healthcare delivery.

Well developed private sector: The corporate sector has embraced South Africa as an entrée onto the rest of the continent.  As a result, the country enjoys higher than average GDP (in comparison to the rest of the continent).  This also has allowed the private health sector to expand substantially.


1.      WHO, Country Cooperation Strategy at a glance: South Africa (2006),

2.      South Africa, Health care in South Africa

3. Harrison, David (2009) An Overview of Health and Health care in South Africa 1994 – 2010: Priorities, Progress and Prospects for New Gains, A Discussion Document Commissioned by the Henry J. Kaiser Family Foundation

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