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Apartheid Legacy Remains in S. Africa’s Health Spending

  • Joe DeCapua

In South Africa, despite the end of apartheid, there is still a big gap when it comes to health care spending. A new study says the richest provinces - where most of the whites live - still receive more government funded healthcare than the poorest provinces.

The research was led by Dr. David Stuckler, a research fellow at Oxford University and the London School of Hygiene and Tropical Medicine. He says, “We found that in many respects the situation hadn’t changed.”

The research followed South African health spending from 1996 to 2007.

“What he found,” says Stuckler, “was a major gap between the richest, most white and most urban provinces and the poorest, most rural and most black provinces that widened over time.”

The study says, for example, in 2007, Northern Cape Province received the most government funding at (US)$168 per capita compared with $101 in Limpopo.


“That’s what our study aimed to understand. We saw a change in the late 90s coinciding with hard economic times and a combination of policy changes where it appeared that the government began investing resources to build clinics, fund doctors, support a functioning health system where there were already more resources in place,” he says.

The Oxford research fellow says such a policy can make sense in the short term “because the regions that already have the functioning clinics can do more with the money invested. But in the long run, it leaves the regions that historically were behind before apartheid just as far behind today.”

Asked whether the government can simply alter its allocations, Stuckler says, “The South African government can act to break what has become a vicious cycle in which the gap between the richest and poorest parts of the country is widening. They attempt to do so, at least ostensibly, with the treasury’s equitable shares formula.”

He explains, “That included a so-called backlog component, which was designed to account for the major inequalities that existed historically. The problem is that component was only three percent of the overall formula. Its weight is ultimately a political judgment. So, yes, we do hope to see changes in the new administration under (President Jacob) Zuma.”

The study says pro-poor policies are “insufficient to counteract historical inequalities or to prevent them from worsening further.”

Simply a matter of money?

“Just throwing money at a problem,” he says, “isn’t going to be enough to solve it. But true commitment can best be judged by the decision to spend money. And without it, we’re seeing a lack of resources to make up for long standing shortages of doctors, clinics and overall health system resources to care for the health needs of deprived black populations.”

The study analyzes the aftermath of Nelson Mandela’s stated mission “to eradicate the legacy of poverty and inequity that is the greatest threat to our public health.”

Stuckler says, “South Africa is in many ways unique for having a commitment to a quality of health care access enshrined in its constitution. Yet, when you look beyond the rhetoric to see how people’s lives are being affected, is there greater access going to the places that were historically deprived? Disappointingly, and a bit to our surprise, we see the situation has not begun to move in as equitable a direction as promised.”

The study appears in the American Journal of Public Health.