About this site

This resource is hosted by the Nelson Mandela Foundation, but was compiled and authored by Padraig O’Malley. It is the product of almost two decades of research and includes analyses, chronologies, historical documents, and interviews from the apartheid and post-apartheid eras.

Endnote on Health

Health Care System

According to SouthAfricaInfo.com, "South Africa's health system consists of a large public sector and a smaller but fast-growing private sector. Health care varies from the most basic primary health care, offered free by the state, to highly specialized hi-tech health services available in the private sector for those who can afford it.

"The public sector is under-resourced and over-used, while the mushrooming private sector, run largely on commercial lines, caters to middle- and high-income earners who tend to be members of medical schemes (18% of the population), and to foreigners looking for top-quality surgical procedures at relatively affordable prices. The private sector also attracts most of the country's health professionals….

"The number of private hospitals and clinics continues to grow. Four years ago there were 161 private hospitals, with 142 of these in urban areas. Now there are 200. The mining industry also provides its own hospitals, and has 60 hospitals and clinics around the country.

"Most health professionals, except nurses, work in private hospitals. With the public sector's shift in emphasis from acute to primary health care in recent years, private hospitals have begun to take over many tertiary and specialist health services.

Public health consumes around 11 percent of the government's total budget, which is allocated and spent by the nine provinces. How these resources are allocated, and the standard of health care delivered, varies from province to province. With less resources and more poor people, cash-strapped provinces like the Eastern Cape face greater health challenges than wealthier provinces like Gauteng and the Western Cape. See SouthAfrica.info, "the all-in-one official guide and web portal to South Africa," at www.southafrica.info/ess_info/sa_glance/health/health.htm

Eighty percent of South Africans live without medical aid, relying instead on government hospitals and clinics for care. Simultaneously, health care spending has declined in South Africa, while many services have been contracted out to nonprofit providers. Many believe that patients at South African public hospitals receive low-quality health care, due primarily to staff shortages; a dysfunctional relationship between hospitals and provincial health departments; and dysfunctional internal management structures. See Karl von Holdt and Mike Murphy, "Failing health of public hospitals," Business Day, 6 December 2006, and their chapter, "Public Hospitals in South Africa: stressed institutions, disempowered management," in Sakhela Buhlungu, John Daniel; Roger Southall; Jessica Lutchman (eds), State of the Nation: South Africa 2007 (Cape Town: HSRC Press, November 2006), which can be viewed at  www.hsrcpress.ac.za/full_title_info.asp?id=2183.

Nationwide, roughly one-third of medical positions in state hospitals remain vacant; 60 percent of South Africa's doctors work in private practice, serving less than 20 percent of the population. Since 2000, the number of registered doctors working nationwide in the public health sector has dropped from 52 percent, to 37 percent in 2004, despite the fact that the number of registered doctors had increased by 11,500. In November 2006, the Wits School of Public Health presented these data to the Gauteng legislature's health portfolio committee.  Among their findings: unlike the nursing sector, in which there is a shortage of people choosing nursing as a profession, doctors prefer private sector pay and working conditions; as experienced public sector doctors retire, there are few new ones in the pipeline to replace them, despite aggressive recruitment efforts and the purchase of high-tech equipment for hospitals. See Chantelle Benjamin, "Sickening shortage of state doctors in Gauteng," Business Day, 8 November 2006.

One problem affecting the provision of health care in South Africa is the migration of skilled workers to other countries. In 2001, according to a study conducted by a University of KwaZulu-Natal research group, Africa lost roughly one-third of its skilled professionals in recent decades, at an estimated cost of about $4 billion. Estimates are that about 37 percent of South Africa's doctors and 7 percent of its nurses and midwives work in developed countries, with roughly 300 trained nurses leaving South Africa every month, according to a report by Oxfam and WaterAid called In the Public Interest: Health, Education, and Water and Sanitation for All.. A copy can be downloaded by visiting the Oxfam website at www.oxfam.org.uk

According to John Battersby, the UK country manager, International Marketing Council of South Africa, there are an estimated million or so South Africans now living in Britain, of whom as many as 50 percent arriving within the past 15 years.  Many of these are health professionals-doctors and nurses being hired by the British National Health Service and private sector companies.  The Council is leading Global South Africans, a network of influential South Africans living abroad, in an effort to transform the "brain drain" into a "brain gain", thus supporting the economic and development revival of South Africa. See John Battersby, "Focus on skills to speed up changing brain drain to gain," Cape Times, 31 March 2006.

But it will take more than ex-pats to fill the gaps in South Africa's health care system. Improved salaries and better working conditions will help reduce the serious shortage; while South Africa is not one of the worst affected countries, according to the World Health Organization's Global Health Report, it does suffer from the exodus of medical professionals who leave the country in search of better opportunities and pay. See Jillian Green, "Let's hold on to our health workers," The Star, 7 April 2006. In January 2007, the South African Medical Association warned that increasingly, even in the private sector, trained doctors and nurses are harder to come by. In 2006, the South African Medical Journal cautioned that the rural health care system will likely collapse, due to new rules affecting medical students that will require two-year internships, thus reducing by an estimated 78 percent the number of doctors eligible for community service. The South African Medical Association argues that the problem is not just the emigration of professionals offshore to places like Australia, Canada, New Zealand, Britain, and the US; it also is due to the shortage of medical schools, with four of the nine provinces having none. See Di Caelers, "Private sector hit by doctor shortages," Cape Argus, 19 January 2007.

The government closed nursing colleges in the mid-1990s, dramatically reducing training opportunities; the National Labour and Economic Development Institute (Naledi) has recommended that they be reopened, a proposal accepted by the cabinet in January 2006. Meanwhile, the Western Cape health department has undertaken an innovative approach to the nursing shortage by training "compassionate and caring" hospital cleaners, porters, or administrators to work with qualified nurses to lighten their caseloads. They receive provincial funding for training to become nursing assistants, performing such duties as turning patients in their beds when they cannot do so themselves; performing non-nursing clerical duties such as filing out forms; making beds; washing patients; monitoring vital signs; and helping with intake and home care. See Di Caelers, "Nurse shortage gives others a chance to shine," Cape Argus, 10 October 2007.

Disease and Mortality Rates


Value (year)

Life expectancy at birth (years) males (?)

47.0 (2004)

Life expectancy at birth (years) females (?)

49.0 (2004)

Healthy life expectancy (HALE) at birth (years) males (?)

43.3 (2002)

Healthy life expectancy (HALE) at birth (years) females (?)

45.3 (2002)

Probability of dying (per 1 000 population) between 15 and 60 years (adult mortality rate) males (?)

667 (2004)

Probability of dying (per 1 000 population) between 15 and 60 years (adult mortality rate) females (?)

598 (2004)

Probability of dying (per 1 000 population) under five years of age (under-5 mortality rate) males (?)

72 (2004)

Probability of dying (per 1 000 population) under five years of age (under-5 mortality rate) females (?)

62 (2004)

Total expenditure on health as percentage of gross domestic product (?)

8.4 (2003)

Per capita total expenditure on health at international dollar rate (?)

669 (2003)

Population (in thousands) total (?)

47,432 (2005)

Per capita GDP in international dollars (?)

8,506 (2004

Source: World Health Organization Core Health Indicators


Death rates in South Africa rose between 1997 and 2004 for almost all age groups, with the exception of males aged 15 to 19. The death rates, according to Statistics South Africa, more than tripled for females aged 20 to 39, and more than doubled for males aged 30 to 44. Overall death rates from infectious diseases tripled for males and were five times greater for females during this same period, with HIV the primary culprit. Other registered causes of death include infectious diseases such as measles and influenza; tuberculosis; parasitic diseases such as malaria; and illness caused by other nutritional deficiencies. Malaria death rates rose between 1997 and 1999, then declined between 1999 and 2004. However, for males the overall death rate from malaria was 45 percent higher in 2004 than it was in 1997; for females it was 93 percent higher.

Non-communicable diseases caused a large portion of the deaths of elderly people, increasing 45 percent for males and 60 percent for females. Cancer, stroke, hypertension, and other circulatory causes, when combined, rose 12 percent between 1997 and 2004.

See Trevor Oosterwyk, "Dying, the beloved country," Cape Argus, 7 September 2006; and StatsSA, Adult mortality (age 15-64) based on death notification

data in South Africa: 1997-2004 (Pretoria: StatsSA, September 2006), which can be downloaded at www.statssa.gov.za/publications/Report-03-09-05/Report-03-09-052004.pdf

According to a Statistics South Africa report on mid-year population, released on August 1, 2006, the life expectancy for a child born in 2006 is estimated at 49 years for males and 52.5 years for females, which presumes a mother-to-child transmission rate of 32 percent if no HIV treatment program is followed, and 11 percent if such a program is in place.

HIV is currently responsible for an estimated 40 percent of deaths in South Africa, but other diseases pose problems, as well. They include heart disease (7 percent of all deaths), stroke (6 percent), and diabetes (3 percent). According to figures revealed by the South Africa Medical Research Council's Burden of Disease research unity, diabetes kills twice as many people in South Africa than in the US, and five times as many as in the United Kingdom.

Diabetes in South Africa is on the rise, with international diabetes experts warning that one of South Africa's most commonly used anti-Aids drugs could, in the long run, increase diabetes' spread. The drug in question is d4T, one of thee in the standard cocktail for South Africans living with Aids. South Africa's current diabetes prevalence rate for people aged 20 to 79 is about 4.5 percent, with women at significantly higher risk. Estimates are that roughly 8 percent of black women in urban areas have diabetes; in the Western Cape, estimates are that 11 percent of coloured people have it, rising to 30 percent for people over 65. Data from the International Diabetes Federation suggest that, for Africa as a whole, the current average 10 percent incidence rate will spiral to 80 percent by 2025. In addition to its impact on patients and their families, diabetes, according to experts, also will subvert economic gains. Meeting in December, the World Diabetes Congress warned that countries like South Africa must put more investment into diabetes care and prevention. See Di Caelers, "Diabetes warning over top Aids drug," Cape Argus, 6 December 2006; and Di Caelers, "Spend more on disease or lose out on growth, SA is warned," Cape Argus, 6 December 2006.  See also Di Caelers, "Diabetes is top 10 killer in SA," Cape Argus, 7 December 2007.

TB Nightmare

TB is the world's deadliest incurable infectious disease, according to the World Health Organization (WHO), but the prevalence of insidious new drug-resistant strains is wider than previously thought. According to the StatsSA mortality report, "Tuberculosis has long been endemic in much of South Africa, especially in Western Cape. Among the coloured [mixed-race] population in Western Cape, it was estimated that the incidence rate was 365 per 100,000 in 1958 (Donald, 1998). Tuberculosis has often been considered an AIDS-defining illness, but Badri et al. (2002) argue that in areas with high tuberculosis prevalence, this should be reconsidered. It is estimated that in 1997-1998, in South Africa as a whole, 33 percent of all persons who were positive for tuberculosis were also positive for HIV, but in Western Cape, 17 percent of those who were positive for tuberculosis were also positive for HIV (South Africa, Department of Health, 2000b)."

Yet many people die of tuberculosis in South Africa who are not HIV-positive. Moreover, tuberculosis is likely to be a cause of death to which HIV deaths are

incorrectly assigned, according to the Stats SA mortality report, although what portion of tuberculosis deaths are due to HIV is not clear, partly because tuberculosis has long been prevalent in South Africa, especially in the Western Cape.

In 1997, the male death rate due to tuberculosis increased with each successively older age except for a slight decline in the last age group. For females in 1997, the rate increased to age 30-34 and then remained almost constant, with a slight increase in the oldest age group. In South Africa overall death rates from tuberculosis increased between 1997 and 2004; TB accounted for 63,529 of deaths in 2004.

These numbers are expected to rise, due to the emergence of drug-resistant strains of TB in 2006. The advent of Extremely Drug-Resistant Tuberculosis (XDR-TB) is the horrifying consequence of poor management of existing TB, as patients fail to adhere to their treatment, health care practitioners fail to prescribe correct drugs, and the poor quality and supply of TB drugs. XDR-TB is resistant to at least two of the main first-line TB drugs, and reportedly to three or more of the six second-line drugs. Unlike "normal" TB, which can be cured, XDR-TB is virtually untreatable.

Last September, the World Health Organization (WHO) confirmed 53 XDR-TB cases in South Africa, of which 52 were fatal. Most of the patients were also HIV-positive. To date, more than 300 cases have been identified, and at least 30 more are picked up each month. According to WHO, the extent of multidrug-resistant (MDR-TB) and extensively drug-resistant (XDR-TB) strains of TB in South Africa are not currently known. WHO is collaborating with the government to provide technical support and advice in the fight against the disease. According to the Health Department's latest figures, 237 of 350 XDR-TB patients identified in South Africa so far (68 percent) have died. A total of 112 are being treatment, with one patient defaulting on treatment. KwaZulu-Natal has the country's largest share of cases, with 221 out of 247 patients (89 percent) having died. The survivors are all on treatment. See "Extent of XDR-TB in South Africa unknown," Mail&Guardian Online, 4 April 2007, www.mg.co.za/articlepage.aspx?area=/breaking_news/breaking_news__national/&articleid=303829. See also Jilllian Green, "Tuberculosis takes on a whole new dimension," The Star, 30 October 2006; Di Caelers, "Health officials to meet as TB deaths rocket," Cape Argus, 12 September 2006; Sarah McGregor, "New TB strain chokes life out of Tugela Ferry," Business Day, 28 November 2006; Chris Makhaye and Charlene Smith, "Killer TB tightens fatal grip," The Sunday Independent, 10 September 2006; "Extreme TB must be tackled urgently, warn WHO experts," Cape Times, 8 September 2006.

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