We’ve all heard about the infamous apartheid-era health system in South Africa. As a middle-income country, richer than many in sub-Saharan Africa, the Republic of South Africa provided world-class care for White elites, including the world’s first heart transplant. But the majority of people were denied appropriate access to health care. Spatial segregation between populations was a prominent method to sustain inequality during apartheid, with racially-biased policies leading to the creation of ‘‘Black homelands’’ that detached the poorest areas from regions with better health care infrastructure.

What’s happened since apartheid ended? Has health care access improved for the poor in South Africa? In a recent analysis of health system data from the country, we found a surprising result: an inverse and worsening relationship between health care allocations and disease burden after apartheid.

Since apartheid ended, provinces with greater health care infrastructure and a greater proportion of persons of White race gained more resources at the expense of those provinces with greater health burdens and fewer resources. The complete data is displayed here. Compare South Africa’s richest province, Western Cape, and its poorest, Limpopo. In 2007, Western Cape had substantially greater health infrastructure than did Limpopo: 60 private hospitals, 55 public hospitals, and 1246 doctors for a population of 4.8 million, compared with only 6 private hospitals, 44 public hospitals, and 882 doctors for a population of 5.7 million in Limpopo. While people in Western Cape can expect to live a full decade longer than those in Limpopo given their much lower burden of disease, by 2007, Limpopo had been allocated only US$101 per person on health, or 53% less than the amount allocated to Western Cape, US$155 per person.

How could this be? Nelson Mandela and the African National Congress came to power in 1994, and the national government explicitly addressed health equity and access. Health care was enshrined as a constitutional right, and over the next few years the government constructed new health care facilities, provided free maternal and child care, and created new programs for water, nutrition, and welfare. As shown in the graph, healthcare equity initially improved after Mandela came to power. But when Thabo Mbeki rose to power in 1999, something changed. The Treasury’s ‘‘Equitable Shares’’ formula was supposed to redistribute funds from rich to poor regions. But many of the poor regions did not have the “absorptive capacity” to use new funds (no hospitals or doctors to spend the funds on new programs), so the federal money kept going to provinces with pre-existing infrastructure.

Meanwhile, the government introduced a growth, employment, and redistribution (GEAR) strategy that emphasized privatization. Private healthcare companies moved to the richest regions, and setup new infrastructure, since people in those regions could pay for it. This created what we call an “infrastructure-inequality trap”: people who already have infrastructure also have the capacity to “absorb” funds by attracting doctors and resources, and therefore inequality worsens as the people with no initial infrastructure to “absorb” funding fall behind. We tested this theory with several multivariate regressions of time-series data from South Africa, and found this was indeed the case: the richest provinces attracted the most private hospitals, who seem to have attracted the most doctors. A province that had twice as many private hospitals per capita as a peer province that was equivalent in other ways would have obtained, on average, 24.2% more health funding, 13.2% more doctors, and 27.3% more hospitals than its peer from 2002 through 2007. Meanwhile, the poorest were left behind. The findings are summarized in this article in the American Journal of Public Health, and outlined nicely by Science Cafemagazine.

So what can we do to reverse this infrastructure-inequality trap? Epidemiologists have for years described an “inverse care law” in which the sickest populations get the least care, as they’re simply unable to pay. But South Africa’s constitution provides a mandate to redistribute funds to the poor; what’s needed now is to mobilize the Treasury to enact that mandate, as simply distributing funds according to existing formulas doesn’t sufficiently invest in new infrastructure. Someone has to take the initiative to build new infrastructure, not just redistribute the existing day-to-day healthcare funds. Build new hospitals and clinics, and equity may come

Have health inequalities worsened in South Africa since apartheid?