Analysing the progress and fault lines of health sector transformation in South Africa

Abstract

South Africa has implemented a number of policies that focus explicitly on equity and that seek to provide redress to those most affected by previous apartheid policies. Examples include the adoption of a primary health care approach, which in itself is a social justice philosophy, and the use of a combination of legislative, policy and resource allocation levers to achieve transformation and to improve population health. This chapter explores the disconnections between progressive and far-reaching health policies in South Africa and the fault lines in implementation. Notwithstanding the progress made since 1994, the chapter presents a critical analysis of and reasons for the relatively poor performance of the South African health system compared with other countries of similar income level, and in light of the country's quantum of health care spending. Three fault lines are identified: tolerance of ineptitude as well as leadership, management and governance failures; lack of a fully functional district health system, which is the main vehicle for the delivery of primary health care; and inability or failure to deal decisively with the health workforce crisis. These fault lines have negative consequences for patients, health professionals and policy implementation. Patients, who are relatively powerless, bear the brunt through negative experiences and sub-optimal care. Health care providers on the front line and at the bottom of the hierarchy also suffer. Faced with an unsupportive management environment, staff shortages and health system deficiencies, they find it difficult to uphold their professional code of ethics and provide good quality of care. The chapter concludes with a call for the metaphorical 'repair of the fault lines' to ensure the success of the proposed national health insurance system.

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