Health care for black South Africans in poor parts of the country appears to be worsening. Comparing health care funding to measures of need, health care inequality in the nation is even more extreme than it is was under apartheid -- two decades after the forced segregation ended. So concludes a new study published in the Dec. 9 issue of the American Journal of Public Health. The researchers compared availability of health care resources to income levels and disease burden, and found that early post-apartheid gains have faltered. For example, by 2007, according to the researchers findings, Northern Cape province received the most government funding -- $168 per person per year -- compared with US $101 per person per year in mostly-black and poor Limpopo province. The wealthier province had twice as many doctors and four times as many hospitals per capita. “Those that already have the best health resources are in the best position to get more,” says UCSF internal medicine resident Sanjay Basu, MD, PhD, a co-author on the study. After apartheid collapsed, the new government headed by African National Congress leader Nelson Mandela made health care a priority. “The right to health care was written directly into the constitution,” Basu says. The reversal of early post-apartheid gains corresponds to changes in government policy in the late 1990s. The Minister of Health stopped earmarking health resources to disadvantaged regions. In addition, the Department of Finance began disbursing block grants for general social spending, including health care spending, to each province. The formula for this allocation resulted in less spending autonomy for poorer provinces. Secondly, according to study authors, “The government introduced a Growth, Employment, and Redistribution (GEAR) strategy that emphasized privatization and fiscal austerity. Comprehensive implementation of GEAR reforms began after Thabo Mbeki assumed the presidency in 1999. The change in administration coincided with declines in public health spending and a substantial increase in private-sector investment in health care, particularly in the wealthiest provinces.”
Health Care Inadequate for Poor Blacks, World-Class for WhitesBasu began his statistical investigations of health care expenditures, disease burden and wealth as a graduate student working with study co-authors David Stucklerp, PhD, MPH, from Oxford University, and Martin McKee, MD, DSc, from the London School of Hygiene and Tropical Medicine. The researchers aimed to identify indicators of how health care finances are distributed to different provinces by looking at trends through time rather than simply measuring loose correlations at single time points.
“During apartheid resources that were mostly distributed to the white population were really very expansive and truly world-class,” Basu says. “In fact, heart transplants were invented in South Africa.” The South Africa Department of Treasury developed a formula for distributing tax dollars for health care, which was supposed to allow poorer areas to catch up. However in the late 1990s, the large-scale privatization of health care insurance begun under Mbeki led to a reversal of the early post-apartheid trend toward less health care inequality. “People in poor areas could not pay for privatized health care. The public hospitals closed, and the private hospitals became more concentrated in places where more people could pay,” Basu says. “The wealthiest were still getting the most health care dollars, and in fact sometimes more than during the last years of apartheid.” Some additional public funds still remain available for the poor to gain access to private health care for specific purposes, such as emergencies.
Infrastructure and Inequality Trap“The highest burden of illness was very strongly and negatively correlated with the amount of funding received over time, controlling for other poverty-associated factors such as income, rural status and the amount of other funds that were being spent on the poor,” Basu says. Health care burden in the study was measured by calculating rates of infant mortality, HIV infection and overall death rates. “The places that already have health-care infrastructure have the resources to make new hospital wings and hire new doctors,” Basu says. “Then they get yet more funding because they can show results. “ “The poor keep getting poorer. They have nothing to begin with and nobody is making the initial investment to build them a hospital where they can afford real health care. We call this an ‘infrastructure-inequality trap’.”
American Journal of Public Health Published Online Dec. 9, 2010