Before the 1994 general election, which heralded in South Africa’s first democratically elected government, Rina Venter, the National Party’s health minister, told me how F W de Klerk, the last apartheid president, had asked her to get rid of racial discrimination in the country’s health system.
Venter convened the state law advisers and repeated the request to them – only to find out that there were, in fact, no laws in place to segregate state hospitals and never had been.
Hospital administrators and doctors had implemented an inhumane system largely because they believed it was expected of them to do so.
Heaven only knows how many people failed to survive this voluntary and unenforced system of racial segregation, but it is a safe bet that more are now suffering as a result of the prevailing incompetent leadership, shoddy teaching and corruption in a health system that is quite literally “crumbling” – a word Aaron Motsoaledi, the current health minister, uses in instances of unusual honesty for a politician.
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AIDS alone will have boosted the “kill rate”, according to a Harvard University team that studied the results of the failure to give anti-retrovirals to HIV-positive pregnant women, and found that around 300,000 babies had died unnecessarily during Thabo Mbeki’s tenure as president.
A report entitled 2008, Countdown to 2015: Tracking Progress in Maternal, Newborn and Child Survival, which aims to track country-level progress towards the achievement of the Millennium Development Goals that relate to maternal and child health, reported that South Africa was one of 68 priority countries that had made no progress.
The country had, in fact, slid backwards, with the report indicating that child mortality had increased and revealing that under-nutrition was an underlying cause of many of the deaths of children under the age of five.
This was during the era when HIV/AIDS infections exploded. However, Mbeki, then the South African president, still has not accepted that the HIV virus causes AIDS. The result was that HIV infection rates tripled between 2004 and 2006.
These are far from the only indicators that after the end of apartheid, the dream of improving healthcare not only failed to materialise but turned into a nightmare we face today.
A public/private divide
The South African healthcare system can essentially be divided into public and private.
In a country of 49 million people, some eight million are covered by health insurance, referred to as medical schemes. It is a system where the scheme makes no profit but those who are paid from it – private hospitals, doctors, et cetera – do.
Up until a short while ago, the division may have appeared racial. Most of those with health insurance were white, while blacks mainly used the public health system. But now, of the eight million with health insurance, approximately half are black.
Most of the insured are not whom you would term “wealthy”. Many civil servants, who generally earn quite small salaries, have this type of health insurance.
Of course, the majority of those using the public health system are still black and poor.
But the starkest contrast between public and private healthcare in South Africa is to be found not in the colour of its patients but in the facilities it offers.
Run-down buildings, missing medication and widespread corruption characterise the public health system, and not a day passes without a story about broken equipment leading to deaths or facilities closing because they cannot afford to pay their creditors.
The private healthcare system, by contrast, features world-class hospitals, the most advanced equipment and, before they emigrate, the best doctors – for most will work where they can earn the best salary and, in South Africa, that is in private healthcare. The result is that the quality of private care is much better than that offered in the public healthcare system.
But 40 million South Africans – and an additional approximately three million refugees – must rely on a system that is falling apart.
Corruption and incompetence
Health Minister Motsoaledi talks a good game and seems to possess a degree of recognition of the poison chalice that is now in his hands. This, however, sometimes presents itself in a churlish criticism of private healthcare.
He intends to introduce a national health insurance system but rather than, in his words, opting for a “big bang” approach, his plan will take 14 years to implement.
Meanwhile, as Nelson Mandela arrives in the Eastern Cape to celebrate his 94th birthday in his birthplace, Siva Pillay, the region’s superintendent-general, who has spent a large amount of his time trying to clear out the rot of corruption in his province, is in charge of a provincial health service where doctors and community healthcare workers have been unpaid for months.
So many newborns lost their lives in the province that the previous health minister, Manto Tshabalala-Msimang, who would not give anti-retroviral treatment to HIV-positive pregnant women, declared in 2007 that the region’s doctors and nurses were so incompetent they could not diagnose major killers like pneumonia or gastro-enteritis.
When Mandela left his Johannesburg home to fly to the Eastern Cape, he would not have been far from the prestigious teaching hospital attached to the University of Witwatersrand. Newborn babies dying is not unknown here, but when a panel of experts blamed the deaths of seven newborns in one week on viruses brought in by visitors, few of the grieving families believed them.
A source of hope?
The shortage of doctors and nurses is so severe in South Africa that the government is making deals with other countries to borrow their medical professionals. One such deal was just struck with Cuba.
But it is not as though the country cannot afford to employ its own – although corruption and waste may make it appear that way.
South Africa spends 8.6 per cent of its GDP on health, and the country’s budget finally hit 1bn South African rand (about $122m) this year. Furthermore, spending on HIV is not limited to the health department but is also supplemented by social grants. The amount spent on HIV/AIDS has grown by close to 50 per cent over the past three years and is not expected to tail off any time soon.
But the AIDS explosion has led to a huge tuberculosis epidemic and one of the world’s largest epidemics of multi-drug resistant tuberculosis.
South Africa also has the dubious distinction of having the highest rate of foetal alcohol disease in the world. The only positive result from this is that the country has produced some of the world’s best experts on the disease.
But hope lives on in Motsoaledi. He has forced medical schools to take on more students, is building more hospitals and has given himself five years to complete some of the improvements he recognises that the national health service so desperately needs.
Pat Sidley is a South African journalist who is currently completing her masters in Bioethics and Health Law at the University of Witwatersrand.
The views expressed in this article are the author’s own and do not necessarily reflect Al Jazeera’s editorial policy.