The Context of Health Disparities in South Africa

By: Deanna Altomara

This past semester, I had the once-in-a-lifetime opportunity to study health in three different countries: Vietnam, South Africa, and Argentina. While I was stunned by many things I learned, I was particularly struck by the history of South African healthcare, and the role that colonialism and apartheid have played in contributing to modern-day disparities.

The South African healthcare system has been in a state of continuous flux since the arrival of Europeans nearly four hundred years ago. Since then, the system has been shaped by historical inequities. Although those inequities are no longer explicit, they often now take more insidious forms. Today, the country continues to struggle to create a fair and effective system of health.

Before the arrival of the Europeans, the Khoi-Khoi, San, and other indigenous tribes relied on traditional healers. These healers were skilled in the use of herbs to treat both chronic and infectious disease. As part of my semester abroad program, I learned more about these practices when my class visited the Rondevlei Nature Reserve. There, our guide allowed us to taste, smell, and feel a variety of traditional herbs, such as “rhino bush” and “snake bush.” He also recounted how his mother used to treat his colds by placing a large, purple leaf on his chest. This leaf would suck out the infection.

Modern medicine arrived with the Dutch East India Company and missionaries sent to convert indigenous Africans to Christianity. Up until the twentieth century, South Africa’s healthcare system was a patchwork of missionary workers, doctors employed by the East India company and colonial government, and traditional healers. The first health legislation was passed in 1807, and allowed for the creation of a Supreme Medical Committee to supervise health in South Africa. In 1883, a smallpox epidemic prompted a law instating mandatory vaccination for smallpox.[1] While this measure was probably designed to prevent the Black labor pool from decreasing, it undoubtedly remains a milestone in the fight against infectious disease.

In 1910, the British established the Union of South Africa. Over the next four decades, the government consolidated the healthcare system into a more cohesive network. Community health centers, the crux of rural healthcare, were first created in 1945. Their descendants, primary healthcare clinics, remain a vital part of the South African health system.[1]

Under the apartheid system that started in 1948, healthcare inequities became institutionalized. The black community of South Africa, who comprised 80% of the total population, were forced to live in small territories called bantustans. These territories only took up 17% of South Africa’s total land, leading to conditions of overcrowding and disease.

The bantustans acted as a labor pool for the mining industry, which facilitated the spread of infectious diseases, as miners would work for long stretches of times and have their lungs severely weakened by silica dust in the mines. They would then contract tuberculosis, an infectious respiratory disease, and bring it home when they returned to visit family and friends. Faced with the threat of a decreased or weakened labor reserve, white mine owners tried to reduce workers’ immune vulnerability by exposing them to tuberculosis germs in a process called “tubercularization.”[2]

The bantustans had their own health systems, run either locally or by foreign missionaries. In 1994, the first democratic elections were held in South Africa, ushering in the African National Congress Health Plan.[1] This plan emphasized the importance of preventative care described in the landmark Alma Ata report, which explained that primary healthcare was an efficient and affordable way to reduce disease. Two years later, the state incorporated a system of free primary health care for all.

Access to healthcare was enshrined in the South African constitution as a human right, a landmark triumph for public health, although implementation remains difficult. The bantustans were consolidated into nine regional provinces. Healthcare services were coordinated under three levels of care: primary/district, regional, and tertiary. We had the chance to visit a local clinic, a key part of the district health system. The clinic, like others, was mainly nurse-run and specialized in providing vaccinations, testing and treatment for STIs (including HIV) and tuberculosis, and care for pregnant women and young children.

Insurance remains a major challenge and source of inequity in South Africa. Some people receive insurance through their jobs, but in a country with rampant unemployment, this practice leaves many people vulnerable. Consequently, most people in South Africa do not have insurance or access to private care. Ironically, government workers are required to have private insurance, which removes them from the difficult realities of the public health system. The poor generally contribute to the public insurance system by paying on a sliding scale.[3]

Another major challenged faced by the healthcare system is brain drain. South Africa heavily subsidizes its medical schools, but many doctors prefer to go abroad or work in private care, where wages are higher, once they have completed their mandatory community service hours.

The country now faces a quadruple burden of disease: maternal and child health, chronic disease and mental health, HIV and TB infections, and violence. HIV continues to be an epidemic in South Africa, although access to testing and treatment is expanding. In 2010, the government began an intensive national campaign urging people to get tested for HIV. South Africa now has the largest ART program in the world.[4]

Meanwhile, tuberculosis (TB) continues to be a major public health concern in South Africa. Instead of DOTS, a directly-observed treatment program in which medical assistants observe daily medication adherence, clinics distribute medicine on a weekly basis to save time and resources. TB is sometimes more stigmatized than HIV, which is starting to be considered a chronic illness due to recent treatment advances. TB is more common in informal settlements, where it spreads via overcrowding and poor ventilation systems.

Many people see an opportunity for change in the country’s new healthcare plan, tentatively scheduled to be implemented by 2030. This plan would set up a system in which everyone is covered and all people pay taxes on a sliding scale according to their income. However, many people doubt it will come to pass in light of South Africa’s corruption, and some have not even heard of the plan.[3] If designed and implemented appropriately, this plan could be a landmark achievement in the alleviation of health inequity in South Africa.

Although major progress has been made since 1994, South Africa continues to face many challenges in providing fair and quality healthcare for all of its citizens. It is essential that the government invest in a strong public health system to help its people move forward from the traumas of apartheid inequality.

References:

1. Coovadia, H., Jewkes, R., Barron, P., Sanders, D., & Mcintyre, D. (2009). The health and health system of South Africa: Historical roots of current public health challenges. The Lancet, 374(9692), 817-834. doi:10.1016/s0140-6736(09)60951-x
2. Packard, R. (1989). The “Healthy Reserve” and the “Dressed Native”: Discourses on Black Health and the Language of Legitimation in South Africa. American Ethnologist, 16(4), 686-703.
3. Winterton, Laura. (2019). South Africa’s Health System: Past and Present. Lecture.
4. Mayosi, B. M., Lawn, J. E., Niekerk, A. V., Bradshaw, D., Karim, S. S., & Coovadia, H. M. (2012). Health in South Africa: Changes and challenges since 2009. The Lancet, 380(9858), 2029-2043. doi:10.1016/s0140-6736(12)61814-5