Occasional Paper 4/2024
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MAY 2024
Daryl Swanepoel
MPA, BPAHons, ND: Co. Admin
Research Fellow, School of Public Leadership, Stellenbosch University
Is South Africa getting healthier?
The divide between perception and data-driven evidence
(Source: istockphoto.com – Stock photo ID:1678122795)
Abstract
South Africans do not have faith in government’s capacity to adequately manage the public healthcare system. Public perception is that the healthcare system is failing and that authorities have been proven incapable of providing quality healthcare – and the perceptions are impacting the trust needed to underpin advances towards universal healthcare for all. Moreover, it dampens their enthusiasm for the establishment of the recently enacted National Health Insurance (NHI). This paper evaluates public perception against actual health provision indicators and the trends since the ushering in of South Africa’s democratic dispensation in 1994, in order to determine whether the perceptions and data realities are in sync. It finds that public healthcare still has some way to go, but that it is not regressed, rather it is steadily improving. It does not suggest that the authorities can rest on their laurels; it does provide reassurance that the system is not collapsing.
Introduction
Statista produces a health and health systems ranking of countries worldwide on an annual basis. In 2023, Singapore, at the number one spot, dominated the ranking of the world's health and health systems. Out of the 167 countries measured, South Africa ranked 129th. African countries that performed better than South Africa were Seychelles (at position 39), Algeria (at position 70), Cabo Verde (at position 73), Tunisia (at position 79), Mauritius (at position 81), Morocco (at position 86), São Tomé and Principe (at position 94), Egypt (at position 107), Kenya (at position 114), Rwanda (at position 116), Senegal (at position 117), Ghana (at position 119), Malawi (at position 121), Ethiopia (at position 122), Namibia (at position 125), Djibouti (at position 126), Sudan (at position 127) and Tanzania (at position 128). Thus South Africa is ranked 19th in Africa (Vankar, N.d.).
The Statista health index score evaluates various indicators that assess the health of a nation. It also evaluates access to the services needed to “sustain good health, health outcomes, health systems, sickness and risk factors, and mortality rates” (Vankar, 2024).
With regard to Universal Healthcare Coverage, according to the World Health Organisation’s UHC service coverage index, South Africa’s index score was 0.71 out of a possible 1 in 2021. This is slightly above the world average of 0.68 and considerably above the African average of 0.44. This marked a significant increase of 28 points out of 1 over the last two decades, from 0.43 in 2000 to 0.71 in 2021 (WHO, 2024).
Figure 1: South Africa’s UHC service coverage ranking
(Source: WHO, 2024)
Using these two indexes as the yardstick, it is therefore fair to say that in terms of the quality of healthcare, South Africa falls far short of the world standards, but in terms of access to healthcare, South Africa is marginally better than the world average.
This paper aims at contextualising the healthcare trajectory in South Africa to enable public policymakers to make informed decisions, and for the public at large to better understand the state of play as it relates to that trajectory.
The public perception
In the public mind, government is not performing well as it relates to healthcare management in the country. Indeed, in their view, healthcare has been worsening of late.
According to the IPSOS Government Performance Barometer (2023), only 16 percent of respondents were of the view that government was performing very well. Only 43 percent were of the view that government was doing an acceptable job (16 percent very well and 27 percent fairly well). Conversely, 55 percent of the respondents were of the view that government wasn’t performing adequately (23 percent not very well and 32 percent not at all well) (IPSOS, 2023).
It may be worth mentioning that the lower the household income, the more favourable the view of government’s performance in the provision of healthcare services. Seventy-five percent of respondents with no household income had a favourable view of government’s performance (18 percent very well and 57 percent fairly well). However, for those in the highest household income group the favourable view plummeted to only 46 percent (15 percent very well and 31 percent fairly well) (IPSOS, 2023).
Figure 2: Perceptions of government’s ability to manage healthcare (based on income)
(Source: IPSOS, 2023 (Data); Author, 2024 (Graphics))
In terms of specific interventions, it appears that the public are more positive with regard to government’s ability to deliver the services. For example:
In the aftermath of the Covid-19 pandemic, which required the wholesale roll-out of vaccines, it appears the public have faith in government’s ability to manage the distribution of vaccines. More than half of the respondents (57 percent) indicated that they have a favourable view with regard to government’s ability to roll-out vaccines. Forty percent did not have a favourable view, with the remaining three percent not having an opinion one way or the other.
Similarly, in fact more so, the public have a favourable view with regard to government’s ability to address the problem of HIV/Aids. Sixty-three percent of respondents indicated that they thought that government was addressing the HIV/Aids problem fairly well (28 percent) or very well (35 percent). Conversely, only 33 percent (14 percent not very well, 19 percent not well at all) did not think that government was managing the HIV/Aids problem well.
(IPSOS, 2024)
Once again, the data would suggest that the lower the household income, the more favourable the view as to government’s performance to manage specific interventions such as the distribution of vaccines and/or the management of pandemics such as HIV/Aids. That said, in this regard the margins of difference between the various income groups are far less stark, in that there is an overall favourable view across all income groups.
This is illustrated in the graphic (Figure 3) below.
Figure 3: Perceptions of government’s healthcare interventions’ capacity (based on income)
(Source: IPSOS, 2023 (Data); Author, 2024 (Graphics))
What does the data say?
The data tells us that since the advent of the new democratic dispensation in 1994, the authorities have both qualitatively and quantitively improved healthcare in South Africa.
In this paper, qualitative improvements in the delivery of the healthcare system are demonstrated by the improvement of people’s health and mortality, and quantitative improvements are demonstrated by the improvement of resources made available to implement the country’s healthcare system. And both show that the country has systematically become a healthier place in which to live. Healthier, but still with much room for improvement when measured against its peers, for example in BRICS:
Whereas South Africa scored 59.9 on the Statista Health Index, Brazil scored 71.7, Russia 71.4, India 66.2, and China 83.1 (Vankar, 2024).
And in terms of universal healthcare coverage, whereas South Africa scored 0.71 on the WHO’s UHC service coverage index, most of its peers in BRICS (Brazil, Russia, India, China) scored considerably better: Brazil 0.80, Russia 0.79, India 0.63 and China 0.81 (WHO, 2024).
Figure 4: BRICS Health Indexes comparative performance
(Source: Statista: Vankar, 2024; WHO, 2024 (Data); Graphics (Author, 2024))
Qualitative improvements
Maternal health
In the last two decades alone, the rate of still births has declined by 22 percent, from 27 per one thousand in 2001 to 21 per one thousand in 2022.
The infant and under-five mortality rates have declined by a massive 56 percent and 58,9 percent respectively. The infant mortality rate is the number of children under the age of one year that die annually, and under-five mortality rate the number of children under the age of five years that die annually.
With regard to the infant mortality rate, there were 55,2 children per one thousand children under the age of one that died in 2002. This reduced to 24,3 in 2022, representing an improvement of some 56 percent in the last two decades (CRA, 2023a).
With regard to the under-five mortality rate, there were 74,7 children per one thousand children under the age of five that died in 2002, which reduced to 30,7 children per one thousand children under the age of five in 2022, representing an improvement of some 34 percent in the last two decades. In 1990, the under-five mortality rate was 59,2, which reduced to 32,8 in 2021, thus reducing by a substantial 44,6 percent over the period (CRA, 2023a).
The pneumonia rates in children under the age of five have also improved considerably over the last two decades. Whilst the actual number of admissions has increased slightly since 2011 – that is, from 39 465 to 40 588 in 2022 or some three percent (CRA, 2023a) – the under-five population has grown by around five percent, from 5,542 million in 2011 to 5,812 million, over the same period (Unicef, N.d). The case fatality rate reduced from 5,8 percent in 2011 to 1,7 percent in 2022 (CRA, 2023a), that is an improvement of some 59 percent.
The statistics for diarrhoea in children under five are similar, where the case fatality rate has reduced from 4,3 percent in 2013 to 1,8 percent in 2022 (CRA, 2023a), representing an improvement of some 58 percent over the last decade alone.
Figure 5: Qualitative improvements in maternal health – stillborn and mortalities
(Source: CRA, 2023 (Data); Author, 2024 (Graphics))
Figure 6: Qualitative improvements in maternal health – Pneumonia and Diarrhoea
(Source: CRA, 2023 (Data); Author, 2024 (Graphics))
Selected diseases
There have been significant improvements in the treatment of disease.
In 1996, just after the transition to the new democratic dispensation, the death as a proportion of malaria cases was 0,6 percent. This has remained more or less constant, fluctuating slightly up or down over the period 1996 to 2022. It was 0,8 percent in 2022.
In 1996, just after the transition, there were 27 035 measles cases in South Africa. Whilst it increased to peak at 64 622 cases in 2000, it has since come down to 4 109 cases in 2022 (CRA, 2023a). Put otherwise, if one takes into consideration the increase in population, from 40,6 million as per the 1996 census (Stats SA, 1996) to the population as per the 2022 census, namely 60,6 million (Stats SA, 2023), the ratio of cases to population in 1996 was 1:1501 and 1:15089 – tenfold improvement. That said, the health system remains vulnerable to unforeseen outbreaks.
The tuberculosis prevalence rate – that is, the number of people with TB per 100 thousand people – has improved significantly. In 1994 it was 444; in 2019 it was 360. This represents an improvement of around 19 percent. And the TB death rate has remained more or less constant since 1994, where the number of deaths owing to TB reported in that year per 100 000 people was 42. It declined by around ten percent to 38 in 2021.
Whilst the proportion of the total population living with HIV has increased from 8,1 percent in 2002 to 13,9 percent in 2022 – a 72 percent increase – the total number of new infections per year has more than halved since 2009. In 2009 there were 417 313 new cases recorded, which reduced to 187 394 in 2023. So too, due to the massive roll-out of ARTs, the HIV-related deaths of children under the age of five has shown a sharp decline, from 13 000 deaths in 1996 to 2 100 deaths in 2022 (CRA, 2023a).
Mortality and life expectancy
Mortality and life expectancy is largely the consequence of lifestyle and healthier living. The healthier one is, the longer one lives. The better the healthcare system and access to it, the better one’s ability to live a healthy life, and thus live longer.
The mortality rate in South Africa suffered a serious setback over the period 1994 to 2008. In 1994 the number of deaths per one thousand of the population was 8,6 (Macrotrends, N.d.). Then the country was struck by HIV/Aids, which ravaged the South African nation.
The death rate per one thousand of the population rose sharply, peaking at 13,9 per thousand of the population in 2008 (CRA, 2023b). Since then, following the mass roll-out of healthcare interventions aimed at stemming the impact of HIV/Aids, it has steadily declined and stood at 8,8 per thousand of the population in 2020, more or less the same as in 1994.
It again showed a marginal regression over the period 2020 to 2022 by rising to around 11 per one thousand of the population (CRA, 2023b) – the impact of the Covid-19 pandemic. The cumulative Covid-related deaths in 2023 stood at 102 595.
The UN, however, projects that the death rate per one thousand of the population will improve by the end of this year (2024) to just over 9 per thousand of the population, once again, more or less in line with the 1994 rate (Macrotrends, N.d.).
The data related to life expectancy, on the other hand, tells a different and more positive story.
In 2002, the life expectancy of a South African by birth was 55,5 years. This has improved by 13,2 percent since then. The life expectancy of a South African increased to 62,8 years in 2022 (CRA, 2023b).
In 2020 life expectancy was in fact even higher at 65,4 years but declined during the Covid-19 pandemic and is steadily recovering to pre-pandemic levels.
Figure 7: Mortality rate in South Africa (2002-2022)
(Source: Stats SA (2022))
The life expectancy of South African women has always been higher than South African men, but the gap has also steadily been widening in favour of women. Since 2002 their life expectancy has improved by 14,1 percent, whereas their male compatriots’ life expectancy over the same period has improved by 12,8 percent.
Quantitative improvements
In this section the financial, human and physical resources made available by the state to implement its healthcare mandate will be examined, as well an assessment as to whether efficiencies have improved.
Improvement in resourcing
Financial resources
In 1996/7, just after the transition to the new democratic dispensation, R24,8 billion was allocated in the national budget to provincial and national health expenditure. The population at the time was 40,58 million (Stats SA, 1996). Accounting for inflation, this would amount to R115,1 billion in present day value (Crause, N.d.).
The amount spent by the state on healthcare per citizen thus amounted to around R611 per citizen. It equated to 3,4 percent of Gross Domestic Product (GDP). Accounting for inflation, this would amount to R2,882 per citizen (1996/7) in present day value (Crause, N.d.).
The allocation grew to R255 billion rand in 2024, which amounted to 3,6 percent of GDP. The population in 2024 is estimated to have grown to 62,47 million (Statista, N.d.). The amount spent by the state on healthcare per citizen thus amounted to around R4,082 per citizen (2024).
Therefore, not only has the budget allocation more than doubled in real terms (present day value) over the last three decades, the amount spent per citizen in real terms (present day value) increased by one and a half times over the same period. And the percentage of GDP spent on public healthcare in South Africa rose marginally since transitioning to the new democratic dispensation in 1994.
People to public doctor ratio
In the year 2000 there were 11 473 doctors in the public healthcare system. This rose sharply by 93 percent to reach 22 158 in 2022, almost double (CRA, 2023a).
In 2002, there were approximately 3 808 people per public doctor in the public healthcare system. The people to public doctor ratio, came down sharply since then. In 2022 there were 2 735 people per doctor in the public healthcare system, equating to an improvement of 28 percent over the period (CRA, 2023a).
Therefore, not only were the authorities able to increase the number of doctors to keep up with population growth, but they also managed to improve the people to public doctor ratio considerably.
People to public nurse ratio
In the year 1998 there were 123 755 nurses in the public healthcare system. This number of nurses in the public healthcare system rose sharply since then, to reach 271 047 in 2022, a weighty 119 percent increase (CRA, 2023a).
In 2002, there were approximately 340 people per nurse in the public healthcare system. The people to public nurse ratio, came down sharply since then. In 2022 there were 244 people per public nurse in the public healthcare system, also equating to an improvement of around 28 percent over the period (CRA, 2023a).
Therefore, not only were the authorities able to increase the number of nurses to keep up with population growth, but they also managed to improve the people to public nurse ratio considerably.
Other public healthcare professionals
Across most healthcare professions the people to healthcare professional ratio has, as in the public doctor and public nurse ratios, shown significant improvements.
The people to public pharmacist ratio has reduced from 40 263:1 in 2000, to 10 491:1 in 2022.
The people to registered physiotherapist ratio has reduced from 9 459:1 in 2007, to 7 100:1 in 2023.
The people to registered radiographer ratio has reduced from 8 686:1 in 2007, to 7 030:1 in 2023.
(CRA, 2023a)
Figure 9: Quantitative improvements – People/healthcare professional illustration of proportional change
(Source: Author, 2024)
Improvement in efficiencies
In-patient hospital bed utilisation rate
In 2015 the in-patient bed utilisation rate in South African public and private hospitals was 72 percent. In 2022 it reduced to 65,9 percent, a reduction of around six percent (CRA, 2023a).
Viewed through a negative lens, it means that there has been a six percent reduction in the utilisation of available beds over the period; viewed through a positive lens, there is significant capacity within the system for the foreseeable future to accommodate in-patients.
Average length of stay in public hospitals
In 2008, the average number of days that a patient spent in a public hospital was 6,4 days. This reduced marginally to 6,1 days in 2022 (CRA, 2023a).
This represents a marginal improvement in in-hospital efficiency.
Vaccination and immunisation of children
Over the last five years alone, the percentage of children receiving their prescribed vaccinations – that is, the DTaPb -IPVc -Hibd HBVe 3rd dose coverage – rose from 76,6 percent in 2018, to 87,6 percent in 2022 (CRA, 2023a).
Antenatal clients initiated on ART
The antenatal clients initiated on ART rate measures antenatal clients on ART as a proportion of the total number of antenatal clients who are HIV positive and not previously on ART.
In 2015, 91,2 percent of people requiring ART received the treatment, which rose to 95 percent in 2022 (CRA, 2023a).
Conclusion
Readers of this paper are cautioned not to conclude that public healthcare in South Africa is in a good space and that the authorities have the luxury to rest on their laurels. They do not! Public healthcare in South Africa still has some way to go before standards comply with acceptable international benchmarks.
What this paper does find is that:
There have been considerable qualitative improvements in public healthcare since the advent of the new democratic dispensation in 1994. There are fewer still births, the infant mortality rate has improved, as has the under-five mortality rate. Pneumonia rates in children have come down, as has the rate of diarrhoea in children under five. There have also been significant improvements in the treatment of diseases such as malaria, measles, tuberculosis and HIV. And South Africans are on average living considerably longer.
There have been significant quantitative improvements in public healthcare resourcing since 1994. The people to public doctor ratio has improved considerably, as has the people to public nurse ratio. This, in fact, holds true across most public healthcare professions.
There have also been marked improvements in public healthcare efficiencies. Both the in-patient hospital bed utilisation rate and the average length of stay of patients in public hospitals have improved marginally. Vaccination and immunisation of children has risen sharply, and antenatal clients initiated on ART is close to universal coverage.
The fiscus has been responsive in providing the necessary funding for the public healthcare system, not to just keep up staffing levels and efficiencies as inherited at the transition in 1994, but to indeed improve on those levels and efficiencies.
What this paper offers:
A contextualisation as to the real, and not perceived, public healthcare environment in South Africa. It ought to assist policymakers in their planning going forward; and
It ought also, should the content be effectively communicated to the broader public, enable them to understand that the provision of public healthcare in the country has systematically improved over the last three decades.
This paper does not suggest all is good in the public healthcare system in South Africa; it does provide reassurance.
References
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This report has been published by the Inclusive Society Institute
The Inclusive Society Institute (ISI) is an autonomous and independent institution that functions independently from any other entity. It is founded for the purpose of supporting and further deepening multi-party democracy. The ISI’s work is motivated by its desire to achieve non-racialism, non-sexism, social justice and cohesion, economic development and equality in South Africa, through a value system that embodies the social and national democratic principles associated with a developmental state. It recognises that a well-functioning democracy requires well-functioning political formations that are suitably equipped and capacitated. It further acknowledges that South Africa is inextricably linked to the ever transforming and interdependent global world, which necessitates international and multilateral cooperation. As such, the ISI also seeks to achieve its ideals at a global level through cooperation with like-minded parties and organs of civil society who share its basic values. In South Africa, ISI’s ideological positioning is aligned with that of the current ruling party and others in broader society with similar ideals.
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