Journeying through South Africa’s healthcare landscape: Triumphs, challenges, and the path to an equitable future

Nestled at the southernmost tip of the African continent, the Republic of South Africa beckons with its promise of democracy and a constitution that guarantees the right to access health services for all its over 60 million citizens. Yet, beneath this veneer of promise lies a stark reality that demands attention. The Human Rights Measurement Initiative’s 2022 study reveals a troubling truth – South Africa falls short of fulfilling the right to health, achieving only 73.4% of what is expected based on its level of income.

In a nation where the constitution enshrines the fundamental rights to food, water, healthcare, and social assistance, these sobering metrics raise alarm bells, especially when it comes to children’s health, where the country manages to achieve just 89.1% of the expected level based on current income. The situation is even more concerning for the adult population, with a dismal fulfillment rate of only 63.8%.

The challenges facing South Africa’s healthcare system are manifold. A triple burden of disease looms large, with communicable ailments like HIV/AIDS and TB, the rise of non-communicable diseases such as diabetes, cardiovascular issues, and cancer, and the ongoing trauma of interpersonal violence, encompassing gunshot and stab wounds, all demanding urgent attention.

To its credit, South Africa allocates 8.1% of GDP to healthcare, equivalent to US$499.2 per capita, showcasing the nation’s commitment to the well-being of its people. Yet, with approximately 42% of this spending relying on government expenditure, policymakers, including President Cyril Ramaphosa’s administration, face the daunting task of extending healthcare access to the most vulnerable sectors of society.

Amidst this landscape, the recently passed National Health Insurance emerges as a potential solution, but its efficacy in addressing deeply-rooted issues that trace back to the apartheid era invites scrutiny from critics. As South Africa grapples with its healthcare challenges, the pursuit of a comprehensive and equitable health system remains an ongoing conversation, seeking to bridge the gaps and ensure that every citizen can access the care they deserve.

Tracing the legacy of apartheid’s impact on South Africa’s healthcare system

South Africa’s healthcare system bears the scars of its tumultuous history, with the shadows of apartheid and racial segregation leaving behind deep-rooted disparities. The country’s journey towards equality has been a long and challenging one, as the black majority fought for their rights against the white minority’s dominance throughout the 20th century. The imposition of apartheid in 1948 led to discriminatory health policies that denied black South Africans the same level of healthcare as their white counterparts, perpetuating inequities that continue to affect the healthcare landscape today.

Despite progress made after apartheid ended in 1994, significant disparities persist in the public healthcare system. The landmark 1996 constitution established nine provinces, each with its own Department of Health, but access to quality healthcare remains uneven. Approximately 80% of the population comprises Black South Africans, who have historically faced marginalization and disenfranchisement. The National Health Act signaled a commitment to equity and inclusivity in healthcare provision, but challenges remained, especially with the emergence of the devastating HIV/AIDS epidemic in the late 1990s.

The epidemic exposed vulnerabilities in the healthcare system, necessitating urgent efforts to confront its scale. As South Africa navigates through uncharted waters, it is driven by a collective determination to heal the wounds of the past and build a brighter, healthier future for all citizens. The quest for a unified and inclusive health system continues, fueled by hope, determination, and the belief that every individual’s right to health should be more than just a promise.

The present: Breaking down the numbers

The statistical data on South Africa’s healthcare landscape provides a comprehensive view of the nation’s well-being, revealing areas that demand immediate attention and progress made towards equitable healthcare for all. The data from Statistics South Africa’s Mid-year population estimates for 2022 highlights critical concerns, such as the gender disparity in life expectancy, with males estimated to live up to 60.0 years and females slightly better at 65.6 years. Infant mortality remains a pressing issue, with an estimated rate of 24.3 per 1000 live births, emphasizing the need to improve maternal and child health outcomes.

The age distribution of the population sheds light on the healthcare demands for different demographics, with about 28.07% of the population being younger than 15 years and 9.2% aged 60 years or older. Provinces like Limpopo and Eastern Cape, with the highest percentage of children younger than 15, require targeted provisions to cater to the unique needs of the younger population.

Disability is another crucial aspect that warrants attention, with about 4.5% of South Africans aged five years and older classified as disabled in 2021. Notably, disability is more prevalent among women, raising questions about gender-sensitive healthcare provisions. Regional disparities are evident, with the Northern Cape reporting the highest rate of disability at 7.1% and Gauteng showing the lowest incidence at 3.1%.

Regarding healthcare coverage, the data indicates a marginal increase in the number of individuals covered by medical aid schemes over the past two decades, though disparities persist across provinces. While Gauteng and Western Cape lead with the highest percentage of medical aid coverage, Limpopo and Mpumalanga report the lowest rates, calling for targeted efforts to extend healthcare coverage and accessibility to underserved regions.

Striving for equitable access to healthcare

At the heart of South Africa’s healthcare system lies the South African Department of Health (DoH), a vital institution entrusted with the nation’s well-being, operating under the National Health Act of 2003. This essential legislation outlines the mandate for a structured and uniform health system, delineating the roles of the three levels of government in providing health services.

At the foundation of the system are the primary care facilities, acting as the first point of contact for patients and offering crucial assessments. Scattered across the country, these facilities are primarily staffed with skilled nurses delivering vital community health services. The second tier comprises district hospitals, where patients can undergo testing and minor procedures, ensuring that health services are accessible to communities in closer proximity. Lastly, the tertiary hospitals form the topmost tier, equipped with advanced infrastructure and cutting-edge technologies to handle major surgeries and complex medical cases, serving as the country’s hubs of specialized care.

However, public hospitals face significant funding constraints, making it challenging to maintain or acquire the latest equipment. As of now, the private sector holds the best prospects for advanced technology and equipment. Four major hospital groups, including Netcare Limited, Life Healthcare Group, Mediclinic Southern Africa, and the National Hospital Network, dominate the private healthcare landscape, alongside several independent private hospitals. Additionally, around 78 medical schemes are operational in South Africa, with 20 being open and the rest restricted. Among them, Discovery Health remains the largest open medical aid scheme, with an estimated 1.3 billion members and 2.8 billion beneficiaries.

South Africa’s healthcare system is divided into two sectors: the public system catering to approximately 85% of the population and the private healthcare sector serving the remaining 15% with access to medical insurance. While both sectors offer various services, the private sector generally offers more advanced, high-tech treatments and elective procedures, leading to comparisons in resource allocation and healthcare outcomes.

Specialist care plays a crucial role in the public health system, especially in tertiary hospitals, where patients with serious conditions receive expert and specialized treatment. To fund the extensive network of over 400 hospitals, the National Revenue Fund collects payments made to local, provincial, and federal governments. Funds are then decentralized to local municipalities, granting public health agencies the autonomy to allocate resources according to their specific needs. This decentralized approach aims to ensure that health services are tailored to the unique challenges faced by various regions of the country.

As part of its vision for the future, South Africa is steadfastly moving towards universal healthcare through the implementation of the National Health Insurance (NHI) scheme. The NHI seeks to make the government the primary procurer of health goods and services while investing in the public healthcare system to bolster infrastructure and enhance accessibility. By pooling resources and optimizing healthcare delivery, the NHI aims to create a more equitable and inclusive system, where every citizen can access quality healthcare without financial barriers.

While the NHI is being phased in, with full implementation targeted by 2026, its progress is subject to multiple factors, including funding availability and political will. The COVID-19 pandemic has introduced additional challenges, impacting the timeliness of the NHI’s roll-out. Nevertheless, the nation remains resolute in its commitment to achieving universal healthcare, ensuring that the dream of equitable access to healthcare for all becomes a tangible reality.

The glaring disparity in the quality of healthcare provided

South Africa’s healthcare landscape is characterized by a profound disparity in the quality of care available to its population, highlighting a clear divide between those who can afford private healthcare and the majority relying on state-provided services. While the country boasts excellent hospital care, it is mainly accessible to those who can bear the costs of private healthcare. Meanwhile, the majority of the population, unable to afford private services, must rely on state hospitals offering low-cost treatment at a subsidized rate. This striking contrast in access to quality care underscores deep-rooted inequities within the system.

The state of the health system is shaped by its tumultuous history, influenced by past epidemics like HIV/AIDS, the COVID-19 pandemic, and the trauma of colonial subjugation and apartheid. These historical legacies have left a lasting impact on healthcare policies and government decisions, contributing to divergent views on the country’s healthcare sector.

A significant statistic highlighting the disparities is that around 79% of doctors in South Africa work in private practice, creating a considerable access gap for those relying on the public system. Private healthcare consultation fees are much higher than those in the state system, emphasizing the inequality in healthcare accessibility for different segments of the population.

Despite comparatively higher healthcare spending compared to other African countries, the improvements in health outcomes have not kept pace with the financial investments made. This disparity further underscores the urgent need to address systemic challenges faced by the public healthcare system, such as underfunding, resource allocation, and healthcare workforce distribution.

Addressing these disparities is not just an economic or political matter; it is a matter of social justice and human rights. Achieving South Africa’s constitutional promise of access to health services for every citizen requires collective efforts from policymakers, healthcare professionals, civil society, and the public.

 HIV/AIDS: A formidable and urgent health challenge for South Africa

The HIV/AIDS epidemic remains a formidable and urgent health challenge for South Africa, posing one of the largest and longest-standing epidemics in the world. The numbers are staggering, with the South African Department of Health (DoH) estimating an overall HIV prevalence rate of approximately 13.9% among the population, accounting for approximately 8.45 million people living with HIV in 2022—the highest number globally.

Confronting this critical issue head-on, the 2023 SA AIDS conference in Durban served as a pivotal platform for evaluating the progress made in combatting HIV/AIDS and tuberculosis in the country. This conference was more than just a gathering; it was an opportunity for organizers to take stock of the post-pandemic response to HIV/AIDS, tuberculosis, and sexually transmitted infections (STIs) while identifying emerging priorities to propel the nation’s efforts in eliminating HIV as a public health threat.

In his keynote address, Health Minister Dr. Joe Phaahla underscored South Africa’s intensified HIV prevention efforts, placing particular focus on pregnant and breastfeeding women, children, and adolescents. This strategic approach aligns with the Global Alliance to End AIDS in Children by 2030, a vital initiative aiming to accelerate progress towards UNAIDS 2025 targets. These ambitious targets seek to ensure that 90% of all people living with HIV know their status, 90% of those diagnosed receive sustained antiretroviral therapy, and 90% of those receiving treatment achieve viral suppression by 2025. Such comprehensive goals are crucial in curbing the impact of HIV/AIDS and shaping a healthier future for the nation.

Recognizing the magnitude of the disease burden, various global interventions have been set in motion within the country. Among the latest endeavors is the PrEPVacc study, supported by the European & Developing Countries Clinical Trials Partnership (EDCTP2) program. This groundbreaking research has initiated human trials of the HIV-PrEP combination vaccine in Durban, offering hope in the quest for effective prevention and treatment options. Innovative research and collaboration play a vital role in combating HIV/AIDS, as the nation relentlessly pursues solutions.

Moreover, the recently launched National Strategic Plan (NSP) for Human Immunodeficiency Virus (HIV), Tuberculosis (TB), and Sexually Transmitted Infections (STIs) 2023-2028 publication emerges as a beacon of hope. This comprehensive and long-term plan aims to foster consensus and drive a well-coordinated, unified response to these three epidemics over the next five years. With the involvement of various stakeholders, communities, and partners, this concerted effort seeks to turn the tide against HIV/AIDS and related health challenges, setting the stage for a brighter and healthier future.

South Africa’s mental health crisis takes center stage as depression soars

In South Africa, the nation faces a growing crisis in mental health, with approximately 16.5% of adults suffering from mental illness, primarily depression. Even more concerning is the fact that 30% of South Africans are likely to experience a mental illness at some point in their lives, demanding immediate attention to this critical public health concern.

The youth of the country are also significantly impacted, with 44.1% experiencing depression and 40.2% experiencing anxiety. Tragically, 1 in 4 young individuals report current suicidal thoughts, highlighting the urgent need for swift intervention and support for this vulnerable population.

Several factors contribute to the prevalence of mental disorders in South Africa, including the demanding work ethic, with Bloomberg ranking the nation as the second “most stressed out” globally. A significant portion of the workforce does not take annual leave, leading to increased stress levels and mental health challenges.

Violence also takes a toll on mental health, with 23% of the adult population exposed to traumatic events related to violence. This exposure leads to a higher prevalence of mental illnesses like post-traumatic stress disorder (PTSD), emphasizing the need for trauma-informed care.

Substance abuse further compounds the crisis, with drug trafficking routes impacting local populations and contributing to substance abuse-related disorders. The lack of access to mental health resources in some regions exacerbates the challenges faced by those seeking help.

Despite the urgency of the situation, South Africa faces disparities in mental health provision, with limited psychiatric hospital beds and restricted access to professional psychiatrists and community mental health facilities. For instance, the country only has 18 beds per 100,000 residents in psychiatric hospitals, falling below the global average, and access to professional psychiatrists and community mental health facilities is limited, particularly in some regions. This glaring gap in resources highlights the need for targeted interventions and increased investment in mental health infrastructure.

In the private healthcare sector, however, a different landscape emerges, offering access to a range of specialists, including psychiatrists, psychologists, and neurologists. Depending on the healthcare provider and insurance plan, individuals may receive treatment without the need for a referral and have treatment costs covered, providing a contrasting reality to those in the public system.

Organizations have launched a petition for the implementation of the Child and Adolescent Mental Health Policy, seeking essential resources and support for mental health initiatives focused on young people.

Addressing cancer as part of South Africa’s quadruple disease burden

South Africa faces a significant challenge with non-communicable diseases (NCDs), forming part of the nation’s quadruple disease burden. Cancer, in particular, stands out as a leading cause of mortality, accounting for about 10% of national deaths. The prevalence of cancer-related fatalities can be attributed, in part, to the disparities in access to cancer prevention, screening, diagnosis, and treatment, leading to poorer health outcomes for many citizens.

Both men and women are impacted by cancer in South Africa, with breast, cervical, basal cell carcinoma, squamous cell carcinoma, and colorectal cancer being the most commonly diagnosed in women, and prostate, basal cell carcinoma, squamous cell carcinoma, colorectal, and lung cancers being the most frequently diagnosed in men. The incidence of cancer cases is on the rise, adding strain to the healthcare system.

Various factors contribute to the disparities in cancer services access, including socio-economic factors, geographical barriers, limited healthcare infrastructure in rural areas, and inadequate awareness among vulnerable populations. The lack of preventive measures and timely screenings further exacerbates the problem.

To address these challenges, the South African National Department of Health (NDoH) developed the National Cancer Strategic Framework (NCSF) for 2017–2022. This framework outlines a comprehensive plan to achieve equitable access to cancer services for all South Africans, prioritizing lung, colorectal, cervical, prostate, and breast cancers, as well as cancers affecting children and adolescents.

South Africa has taken decisive action to combat tobacco use, enacting legislation to curb smoking and reduce exposure to carcinogens found in tobacco products. Early detection and intervention are prioritized through targeted cervical cancer screening programs, and childhood vaccinations against hepatitis B and human papillomavirus (HPV) aim to prevent hepatocellular and cervical carcinomas.

Disease-specific national policy guidelines have been developed to ensure standardized and equitable cancer treatment across the country. Cancer care is provided through both the public and private health sectors, with the public sector working to improve the accessibility of cancer treatment and radiotherapy services available at various oncology centers.

Radiology plays a vital role in cancer management, and the Radiology Society of South Africa (RSSA) provides support and guidance in this field. The radiology workforce has seen significant growth, reflecting the nation’s commitment to enhancing healthcare infrastructure and tackling the mounting cancer burden.

A report published in Cureus in 2022, titled “Temporal Trends in the South African Diagnostic Radiology Workforce,” sheds light on the distribution of radiology personnel in the country. The findings reveal significant growth and transformation in the imaging workforce over the years from 2002 to 2019. During this period, the total number of imaging personnel saw a remarkable increase of 283%, rising from 3,095 to 8,753 professionals. In comparison, the national population grew by 29%, from 45.45 million to 58.77 million.

The youth of the country are also significantly impacted, with 44.1% experiencing depression and 40.2% experiencing anxiety


Modern medical technologies advancing healthcare systems in South Africa

South Africa has made significant strides in embracing modern medical technologies to enhance its healthcare systems and improve patient access and outcomes. Recognizing the potential of digital healthcare technologies, the government has emphasized their integration into the National Health Insurance (NHI) program. The National Digital Health Strategy for South Africa 2019-2024 sets the framework for leveraging digital tools to strengthen healthcare delivery, facilitate patient access, and enhance overall health outcomes.

The onset of the COVID-19 pandemic compelled healthcare practitioners (HCPs) in South Africa to reevaluate and reinvent their patient interactions. The Health Professions Council of South Africa’s Legal and Regulatory Affairs highlighted the growing importance of utilizing advanced and specialized IT solutions in perioperative and critical care settings. The willingness to embrace such technologies has been on the rise, driven by the urgency to adapt to changing healthcare needs and challenges.

South African companies, Afrigen Biologics, and Biovac Institute have taken significant steps in the development and manufacturing of mRNA vaccines. With guidance from the World Health Organization (WHO) and other reputable organizations, they are working towards producing mRNA vaccines locally. This endeavor not only strengthens the country’s healthcare capabilities but also contributes to global efforts to combat infectious diseases.

In a ground-breaking move, the WHO established a technology transfer hub in South Africa in June 2021. This hub aims to harness publicly available information to recreate Moderna’s COVID-19 vaccine and develop a comparable vaccine within the country. By fostering knowledge-sharing and collaboration, this initiative paves the way for increased vaccine accessibility and affordability, benefitting populations not only in South Africa but also in other resource-limited regions.

Building Africa’s medicine hub and boosting self-sufficiency in medicine production

To solidify its position as Africa’s Medicine Hub, South Africa is taking strategic steps to bolster its local pharmaceutical industry and increase its self-sufficiency in medicine production. Despite being a major manufacturer and supplier of pharmaceuticals in sub-Saharan Africa, the country heavily relies on imported products, which account for a significant portion of pharmaceutical sales. However, with a rapidly growing local manufacturing capacity and capabilities, South African pharmaceutical companies are poised to become pivotal players in the production and distribution of essential medicines and COVID-19 vaccines, not only for the domestic market but also for the rest of Africa.

To facilitate this transformation, South Africa revamped its drug regulatory agency, establishing the South African Health Product Regulatory Authority (SAHPRA). With a mission centered on safety, efficacy, and quality oversight, SAHPRA aims to streamline operations and address the country’s backlog of drug applications, ensuring faster and more efficient approval processes for pharmaceutical products.

The country’s resolve to tackle health challenges, particularly the AIDS epidemic, has been instrumental in creating a high-tech hub for pharmaceutical distribution and manufacturing. South Africa’s world-leading antiretroviral program and status as a major producer of radiopharmaceuticals showcase its commitment to advancing healthcare on the continent.

However, the South African government has faced challenges in its relationship with the global pharmaceutical industry, particularly regarding patent rights and access to generic versions of branded drugs. Overcoming this hurdle and expanding its pharma industry’s reach to the international market will be crucial for South Africa’s status as a Medicine Hub.

To foster growth and support the domestic pharmaceutical industry, the South African government can utilize public procurement as a strategic tool. By recalibrating the market through public procurement, it can provide greater protection for local manufacturers, stimulating their growth and competitiveness. Additionally, leveraging regional structures like the African Continental Free Trade Agreement (AfCFTA) can harmonize the African pharmaceutical market and create new regional value chains, fostering industrial and infrastructure development across the continent.

The AfCFTA’s launch in January 2022, with its elimination of import tariffs and promotion of frictionless trade in Africa, is expected to significantly benefit the pharmaceutical industry. As regional integration progresses, the AfCFTA can further boost South Africa’s position as a Medicine Hub and open doors for increased collaboration, investment, and partnerships within the African pharmaceutical landscape.

The potential impact of the NHI plan on South Africa’s pharmaceutical landscape

With the potential realization of the National Health Insurance (NHI) plan in South Africa, a wave of transformations is expected in the pharmaceutical sector. One of the significant shifts will likely be the surge in demand for prescription generic drugs, reflecting the emphasis on cost-effective treatments. Alongside this, improved healthcare infrastructure and enhanced accessibility to medical services will play a vital role in meeting the growing healthcare needs of the population.

The NHI’s implementation is also projected to boost local pharmaceutical production of generics, as the government seeks to bolster self-reliance in the production of essential medicines. However, the challenging economic conditions prevailing in the country could temper the demand and spending in this sector, particularly for high-value medicines.

The COVID-19 pandemic has served as a stark reminder of the gaps and weaknesses in meeting the demand for vaccines and drugs. As a result, there is a growing interest in establishing a robust pharmaceutical and biotech production hub within the country. This initiative aims to ensure preparedness for future pandemics and enhance access to vital medical supplies.

Partnerships between U.S. pharmaceutical manufacturers and local producers have already taken shape, with a focus on technology transfer to ramp up local production for the continent. A significant development in mid-2021 was the World Health Organization’s announcement of its support for an mRNA site in South Africa. This facility will be responsible for producing COVID-19 vaccines for the region, signifying a pivotal step towards medical self-sufficiency.

Currently, most innovator drugs are imported, with primary supply from India, Germany, the United States, and France. However, this import dependency might see slower growth, particularly for newer drugs that may not be included in the Essential Medicines List. In contrast, generic drugs are anticipated to experience robust growth, both in terms of volume and spending. This surge can be attributed to high demand and purchasing preferences in the public sector, along with the government’s policies and incentives promoting local content and production.

South Africa’s BRICS membership: Unlocking healthcare advancements

 South Africa’s affiliation with the BRICS group of nations has opened new horizons for growth, especially in the domain of healthcare and pharmaceutical development. A remarkable milestone in the continent’s journey to enhance its health systems and effectively respond to future pandemics is the recent establishment of the BRICS Health & Pharmaceutical Association of Africa (BRICS-HPAA) within South Africa.

Through the BRICS-HPAA initiative, Africa stands to benefit significantly from the vast research and development capabilities, as well as advanced technologies of BRICS countries, including Brazil, Russia, India, China, and South Africa. By leveraging these collective resources, the association seeks to address the pressing health system challenges that the continent faces.

At the heart of the BRICS-HPAA’s mission is the establishment of a state-of-the-art mRNA and traditional vaccine technology factory. This ambitious project aims not only to eradicate diseases and pandemics in Africa but also to support BRICS-aligned countries. The development of such a facility holds the promise of bolstering healthcare infrastructure, research capabilities, and vaccine manufacturing capacities in the region, strengthening the continent’s resilience against health crises.

The Frontiers Public Health Journal highlights the shared economic development and transformation process among BRIC countries, which led to their grouping. While each BRICS nation follows distinct approaches and grapples with unique challenges in their respective health systems, they share a common commitment to cooperation in the field of health. The decision-makers view BRICS as a potential instrument for shaping global health policies and driving positive changes in the international health arena.

One notable feature observed in the health systems of BRICS countries is the adoption of a mixed public and private responsibility and financing model. This hybrid approach allows for a diverse range of solutions to address healthcare needs, ensuring a dynamic and adaptive approach to healthcare delivery.

As South Africa collaborates with its BRICS counterparts through the BRICS-HPAA, it seizes the opportunity to draw from the best practices, cutting-edge technologies, and rich expertise of these nations. This collective effort is expected to create a transformative impact on healthcare in Africa, advancing access to quality medical services, state-of-the-art pharmaceuticals, and advanced research and development.

This feature appeared in the June 2022 issue of Healthcare Middle East & Africa. You can read this and the entire magazine HERE