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Inequalities in South African health care

Part I. The problem - manifestations and origins

H. C.]. VANRENSBURG, A. FOURIE

Abstract This exposition analyses and contextualises the Amid the broader democratisation process and the con­ complex problem of structural inequality in South comitam universalisation of human rights in South African health care. Socio-econornic conditions, Africa and elsewhere, it is only apt to put the problem of racial divisions and geographical location are iso­ persistent inequalities and the ensuing demands for lated as the main determinants ofinequality in the equalisation - as it has sedimented in the health care provision, allocation and distribution of health field in particular - under renewed scrutiny. W/e are care; the prevailing inequalities are attributed to a convinced that a more equal and equitable dispensation wide range of underlying causes, including the is indeed possible in South African health care, provided absence of a central, binding health policy, the that a more decisive and directive political will to prominent role of apartheid and white domina­ embark on fundamental reform emerges from the pre­ tion, the free market and the medical profession, sent paralysing impasse. The purpose of our exposition as well as the unique sociocultural set-up of the is analytically and systematically to explore the possibili­ country. The urgent need for deliberate strategies ties and prospects of greater equality in South African to equalise the prevailing disparities and discrep­ health care. ancies is posed.

S Atr Med J 1994; 84: 95-99. The nature and types of inequality in health care Inequalities in South African health care arise along present, as has been the case for decades now, various dividing lines according to which the distribu­ ~health care in South Africa is plagued by a multi­ tion and provision of resources are regulated, and they tude of problems, constraints and deficiencies. find expression in various degrees of accessibility, attain­ Their nature relates on the one hand to the healrh care ability, utilisation and quality of services and facilities in system as a provider or distributor of health care and on the health sector. As a result marked inequalities in sup­ the other to the population as cliemele of that system. ply and consumption spill over into significant inequali­ Recently the crux of these problems and their complex ties in the health status and in differential health nsks interrelatedness was aptly depicted as 'a bureaucratic and survival chances for certain population groups and entanglement of racially and ethnically fragmented ser­ people. Inequality in health care in South Africa is vices; wasteful, inefficient and neglectful of the health of therefore no singular and simple problem. As elsewhere, more than two-thirds of the population'. 1 The diversi­ I its origins and guises are numerous. ,2,6, The main fied manifestations of these problems and deficiencies divides from which inequalities in this sector emanate have recently been documented extensively."" In are those of socio-economic status, wealth or purchasing essence, their origin is the many grave disparities in power (rich/poor; insured/non-insured), race or colour accessibility, attainability and affordability of care; this group (white/non-white), and geographical area and stems from severe primary shortages and backlogs in the conditions (urban/peri-urban/rural)'. Despite their availability of personnel, finance and other resources, mutual interplay in actual health care, they are never­ and still more from the maldistribution, malmanage­ theless distinguished here for purposes of analysis. mem, misallocation and misapplication of ava!lable Apart from these broader divides, inequality in South resources. Highly inappropriate emphases and onenta­ African health care also encompasses a myriad related tions in health care, driven by professional, political and dimensions: (i) it manifests itself in disproportionate fmancial interests, have given rise to indiscriminate, distribution and thence also overconcentration and unjustified and wasteful decisions regarding the pro~­ underconcentration of personnel, services and facilities; sion of care. The result is an alarming lack of synchroru­ (ii) it refers to unequal provision and availability of sation and co-ordination in South African health care ­ services and facilities, and to the accompanying over­ both among the various composing parts of a struc­ and underprovision, over- and underservicing, and turally fragmented health care system, and between the problematic phenomena such as over-/underhospitalis­ supply of and the demand/need for services. From this incr, over-/underdoctoring and over-/undermedication; problematic set-up, the question of inequality and (i/i) it is expressed in differential or unequal accessibility inequity in health care emerges most prommently.. of services and facilities together with the phenomena of Also, and particularly owing to the protracted history in-/exclusion from services and amenities, as well as ofthese inequalities and inequities, South African health obstrUctive and discriminatory measures which limit or care is at present at a crossroads. As is .the case. ill SOCI­ bar admission or access to sectors of the health care sys­ ety at large, reform in health ca~e IS pendmg and tem; (iv) it assumes the guise of differential attainability inevitable. ',2,4,'4,15,1S-20 Amid an ever-mcreasmg demand and even unattainability of services and facilities, espe­ for democratisation in the wider, highly undemocratic cially in relation to the location of facilities and the societal dispensation, inequalities in health care have logically become prime targets of the reform process. * In this exposition the focus is on structural inequalities in health cate, Centre for Health SysteII1S Research, University ofthe Orange as t1istinguished from individual inequalities in health; thus on inequal­ ities emanating from and penaining to social, political, economic and Free State, BloeII1fontein 'cultural contexts or sources. Put differently, the inequalities analysed MA, D.PHIL H. C. J. VAN RENSBURG, here penain to the conditions and opponunities regarding the provi­ A. FOURIE, B.SOC.SC. HO>lS sion and distribution of health care as opposed to health outcomes for people. Accepted 24 Feb 1993. ~L.... -"- _

deployment of personnel; (v) it refers to consumption or against disease and indisposition. This implies that mem­ utilisation inasmuch as the clientele do not to an equal bership ofa specific race or colour group constitutes the sec­ extent make use of available services and facilities, ond significant differential connected with inequality in resulting in either excessive, unnecessary and unjustified health care. This cannot, however, be ascribed to coinci­ consumption or underurilisation of services and facili­ dence or mere fate. Many an inequality of this sort has ties; and (vi) it also surfaces in the differential quality of systematically been created and maintained in South services and facilities in the sense that some receive Africa's protracted apartheid history. Apartheid's more and better services and facilities while others oppressive and discriminatq;y measures secured whites receive less and poorer. As a matter of fact, these their privileged position in South African society - the inequalities are closely related to, and are indeed a mere health sector is no exception. In general, the majority of reflection of, the socio-economic, racial and political South Africans (non-whites) were excluded from any disparities in the broader societal context, where access participation in health decision-making by the failure to to wealth and political power so far has been regulated grant them political rights. There is a long tradition of by a white political elite. On the one hand this served to concentrating the health care supply (in terms of both strengthen the privileged socio-economic and political quantity and quality) in favour of the white population. position of the whites, while on the other it perpetuated There is also an equally long history of exclusion ofnon­ a vicious circle of repression, poverty and deprivation of whites from facilities which were reserved exclusively for non-whites. whites or kept separate, but strikingly unequal, for the More about these most marked inequalities in South different colour groups. At present the white population African health care and their multiple manifestations is is better served and provided for in almost every area of to follow. health care, while the other population groups are in markedly deprived positions, the rural and peri-urban blacks being in the most desperate situation. For Socio-economic conditions Benatar23 the elimination of apartheid is indeed the first Variables associated with socio-economic conditions, such and most impottant step towards reducing these dispari­ as mmerial weallh, employment SlaLUS and purchasing ties. Inequalities emanating from the race/colour divide power, represent the first important dimension of in South African health care are listed in Figs. 1 and 2. unequal distribution and provision and of differential accessibility, attainability, utilisation and quality of Total GNP expenditure on health care, RSA 1989/90 -6,4%" health care. The most important cause ofthese inequali­ Total per capita expenditure on health care, RSA 1988 - R283,65'" ties is financial ability, which determines whether people ~ can afford health care, how much and what quality they /' PRIVATE SECTOR PUBLIC SECTOR can afford, and whether they must simply forgo health 45% of GNP expenditure 1989/90 55% of GNP expenditure 1989/90 care. (R5 918,7 million)" (R7 305,3 million)" In South Africa, the wealthy, permanently employed and health-insured undoubtedly have the better health t t care, being in a position to avail themselves ofhigh-stan­ INSURED POPULATION NON-INSURED POPULATION dard private health services. In contrast, the poor, 20,1% of total population 80% of total population unemployed and non-insured find themselves in a rela­ 69,3% of all whites (mainly non-whites)"''' 33,3% of all Asians tively deprived position; for them health care is largely 29,5% of all coloureds unaffordable and financially inaccessible, rendering 6,5% of all blacks"" them dependent on the State and/or on charity, or sim­ ply forcing them to forgo health care. Many factors t nowadays aggravate this situation. On the one hand MEDICAL SCHEME PUBLIC! there is the desperate and ever-worsening socio­ EXPENDITURE (1989) EXPENDITURE (1989) economic position of an exceptionally large proportion • Medicine 26% • Provincial administrations 62,1% • Hospitals 21,6% • Own Affairs 2,9% of the population, among whom poverty, unemploy­ • Specialists 17,6% • Dept of National Health 15% ment and irregular employment are prevalent. On the • General practitioners 16,3% • Local Authorities 1,6% other hand the prevailing free-market dispensation in • Dentists 10,8% • Homelands 18,4%" health care, together with intensified measures to effec­ • Administration 7,7% tuate privatisation, contribute to a situation where finan­ Per capita expenditure on insured Per capita expenditure on non- population (1987) R555''''''' insured population (RSA 1987) R159 cial ability and purchasing power play an increasingly important role in the provision and distribution of health services and facilities, also giving rise to stronger ;::,,"=.=: I manifestations of inclusion and exclusion, overprovi­ Public subsidisation of health Insurance (1988) sion, deprivation and excessive and underurilisation of R1,5 billion" 2 L health care. ",Il,l2,21,22 Inequalities pertaining to socio-eco­ nomic differentials are listed in Fig. 1. t Public subsidisation of health care for whites (1985) R248 Race and colour divisions t Socio-economic inequalities are further complicated in Public subsidisation of health care for non-whites (1965) R82" that they largely coincide with existing race and colour divisions in the population. Whites find themselves, t PER CAPITA EXPENDITURE ON HEALTH (1987)"'''''' generally speaking, in a more favourable socio-economic position than their non-white compatriots. Whites are Whites R591, 11 Asians R356,24 most often to be found in permanent employment and Coloureds R340,16 also have the larger share of health insurance by far ­ Blacks (RSA) R137,84 thereby ensuring their preferential claim on the health Blacks (Homelands) R54,74 care resources ofthe country. Blacks, on the other hand, are generally in a relatively unfavourable to desperate t socio-economic position, proportionally few have the Per capita expenditure on whites = 4,3 times that on non-whites privilege of permanent employment and purchasing FIG. 1. power for private health care, and fewer srill are insured Inequalities in health expenditure in South Africa. _.------'..'-----9'-

Geographical factors urban clientele; on the other hand, this privileged situa­ Geographical area and geographical condirions constitute tion stands diametrically opposed to and obviously the third imponant divide from which gross inequalities aggravates the overloaded 'second-class' public sector I services which have to cater for the poor, non-insured, in South African health care emanate. ,2,24,2' Health per­ sonnel and facilities concentrate in the urban and metro­ mainly non-white rural clientele. From this deep divi­ politan areas, leaving rural areas, and the rural home­ sion in South African health care many a qualitative and lands in panicular, in a relatively underprovided and quantitative inequality emerges. underserviced position. This has yet another, deeper dimension: white business and residential areas in urban areas have a disproportionately high allotment of health The origins/causes of structural personnel and amenities serving mainly the white clien­ tele, resulting in distortions such as overprovision, over­ inequalities in health care servicing and overuse. Yet, in the conesponding non­ In order to contemplate any significant solution to the white peri-urban and squatter areas of those same cities, multidimensional problem of inequality in South such services and facilities are meagrely provided or African health care, it firstly seems necessary to grasp its even entirely absent. These geographically related origins, that variety of forces which introduces, facili­ inequalities are funher aggravated by geographical con­ tates and reinforces the emergence and sedimentation of ditions and impediments. Much of South Africa consists these inequalities. Apart from being the source of much of inhospitable, impassable and vast areas in which ren­ concern and discontent in South African health care, dering of and access to health care is very difficult. these causative forces also indicate departing points Where these areas - especially the homelands - are from and guidelines along which reform and thus the also characterised by \videspread poverty and back\vard­ equalisation of health care provision and distribution ness, and a poorly developed infrastructure, the effects can be launched. of geographical inaccessibility become far worse. In reviewing the historical development of South Inequalities relating to geographical area in South African health care, a myriad events and determinants African health care are listed in Fig. 2. which to a greater or lesser degree instigate and The essence of inequalities in South African health strengthen these inequalities in health care, or particular 2 2 care can be summarised as follows: on the one hand, the dimensions thereof, can be identified. • 6-3O Furthermore, well-developed private health care sector provides a in reducing these formative factors to the most common 'first-class' service to the wealthy, insured, mainly white denominators, it seems reasonable to abstract a few

FACILITIES AND SECTORAL MIX GEOGRAPHICAL DISTRIBUTION RACIAL DISTRIBUTION PROVIDERS Public Private Metropolitan Non·metropolitan Whrtes Indians Coloureds Blacks (RSA) Homelands Hospital beds"-".=q 74% of all beds 26% of all beds 50% of all beds 50% of all beds 1:61 1:505 1:346 1:337 1:417 ACUTE CARE BEDSl1 000 PUBLIC SECTOR DEPENDENT POPULATlON 45% 55% PRIVATE SECTOR 8,2:1000 4,2:1000 2,4:1000 4,5:1000 4:1000 94% 6% 41% of all 59% of all PUBLIC SECTOR PRACTISING DOCTORlPOPULATION RATIOS practising doctors practising doctors 80% of all GPs 20% of all GPs 1:282 1:661 1:10284 1:53543 1:8333 TOTAL DOCTORlPOPULATION RATIO PRIVATE SECTOR 1:2175 1:487 62% of all GPs 38% of all GPs GPIPOPULATION RATIO TOTAL DOCTORlPOPULATION RATlO 1:3007 1:685 1:875 1:12700 1:3030 79% of all nurses 21% of all nurses REGISTERED NURSElPOPULATlON RATIO 1:155 1:592 1:505 1:698 (84,5:10 (00) (17:10 (00) (20:10 (00) (14:10 (00) TOTAL NURSElPOPULATlON RATlO ENROLLED NURSElPOPULATION RATIO 1:368 1:265 Not ameaningful distinction. Nurses 1:943 1:731 1:670 1:330 are mainly employed in public sector (10,6:10 (00) (5,8:10 (00) (15:10 (00) (7,5:10 (00) hospitals and are oonsequently distributed acoordingly. 44,6:10000 (1:224) HIGHEST AND LOWEST FOR HOMELANDS: Ciskei 7,6:10000 (1:1314) KwaNdebele 20% of all dentists 80% of all dentists 57% of all 'general 43% of all 'general TOTAL DENTISTIPOPULATION RATIO < dentists' and 70% .dentists' and 30% of all tooth and of all tooth and mouth specialists mouth specialists in 4 largest metro- in non-metro­ poIitan areas poIitan areas 5:10000 1,3:10000 0,25:10000 0,005:10000 TOTAL DENTlSTIPOPULATION RATlO 1:137970 1:2213 (1:2000) (1:7692) (1:40000) (1:2 million) (Ratio in public sector =62 times that (±90%ofall in private sector) dentists are whITe) Pharmacists"-U 16"10 of all registered 84% of all registered and 10% of all and 90% of all 10% oI,all practising pharmacists In South Africa manage 80% of all pharmaceuticaJ stoe . practising practising

FIG. 2. Inequalities in the provision of health care in South Africa. __98__'--- _

overarching clusters of causes which appear to have REFERENCES made a particular contribution. These can be sum­ I. Medical Research Council. Changing Healch in Souch Africa: Towards marised under five headings. New Perspecuves in Research. MenJo Park, Calif.: Henry J Kaiser Firstly, and from the stan, South African health care Family Foundation, 1991. 2. Van Rensburg HC], Fourie A, Pretorius E. Heailh Care in Souch was strikingly characterised by absence of a cenual, bind­ Africa: SmtClUre and Dynamics. Pretoria: Academica, 1992. ing health policy. Rather, loose and incoherent legislation 3. Andersson N, Marks S, Zwi A, eds. Soc Sci Med 1988; 27(7): has in the course of decades been enacted in this field. (Special issue: 'Health, apartheid and the fromline states'). 4. Benatar SR Medicine and health care in South Africa - five years As a result various problemaTic authon'ty srn/ell/res and pol­ later. 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Inequalities in South African health care

Part 11. Setting the record straight

H. c.}. VANRENSBURG, A. FOURIE

Abstract While Part I ofthis article analysed the problem of refonns'·, i.e. minor material improvements while leav­ structural inequalities in South African health ing intact current political and economic structures and care, this follow-up explores feasible and socially rejecting objectives and demands which are incompati­ accountable principles as well as a policy strategy ble with the preservation of the system.•,5 Entirely new to equalise existing discrepancies and disparities. ways of thillking and progressive measures appear to be In addition, the prospects ofequalising the dispar­ imperative. The following are paramount: ities and discrepancies are weighed against pre­ 1. A re-evaluation of prevailing principles and vailing realities. The conclusion: for the foresee­ value-orientations in South African health care is able future the chances for equality in South necessary. In particular a rerreat from dominant values African health care appear to be rather slim; a sustaining the pluralistic health care system, which serve myriad interest groups with vested interests in the as an unlimited source of inequality, should be made. status quo are at play, opposing any fundamental The values of racial superiority, market-justice and indi­ reform to ensure greater equality. However, what vidualism must be played down in the health sector. At is more important than the acceptance ofthis fate the same time values conducive of equality must be cul­ is our sincere endeavours to minimise these tivated, especially those of co-operation, common good, inequalities. altruism and equity. 2. A refocusing of prevailing policies with a S Air Med J 1994; 84: 99·103. concomitant reorganisation of existing structures of health care also appear necessaty, so as to render services and facilities more available, affordable, accessi­ Equalising the inequalities in health ble and acceptable for the entire clientele, bur also ren­ care dering them less fragmented, more co-ordinated and more effective in their functioning. This clearly means Judging from the complex origins and diversified nature cunailing the roles played in the health care system by of inequalities in South African health care - as apartheid, the private sector, the provincial bureaucra­ described in Part I of this article - a simple and cies and the medical profession in particular. srraightforward approach to equalisation would nor be 3. A redistribution of funds, personnel and applicable and feasible. Instead a broad and multi­ other resources in the health sector to accomplish faceted approach seems necessary. Above all, it appears more equal provision and more equitable allocation also obvious that refonn srrategies that aim fundamentally to seems inevitable. This implies a scaling down of the address inequalities in health care should commence at major role of purchasing power, geographical area and the root causes and their complex interconnectedness, race in the present distribution, provision and accessibil­ thus srretcrung far into the broader, problematic societal ity ofhealth care. 1 order. .' Furthennore, structural inequalities represent 4. In accordance with the abovementioned mea­ but one dimension of the structural problems haunting sures, it would subsequently be a prerequisite to South African health care. An isolated concenrration on explore new value-orientations, new policy frame­ equalisation without addressing the total nexus of prob­ works and measures, alternative models of care lems would therefore be futile. For too long the coun­ and other categories of health care providers, try's health care problems were dealt with by 'reformist which will be able to incorporate easier access, greater relevance and more acceptance into South African Centre for Health Systems Research, University ofthe Orange health care. Free State, Bloemfontein H. C. J. VAN RENSBURG, MA, D.PHlL. :lI 'Reformist reforms' is distinguished from 'nonrefonnist refonns', A. FOURIE, B.SOC.SC. HONS i.e. true and lasting changes in the present system's Structures of Accepted 24 Feb 1993. power and finance.""