The structure and financing of South African health services: future options

The current period of fundamental political change in South Africa offers a window of opportunity for the implementation of transformative health policies. The South African health system is presently characterised by considerable fragmentation of health service provision and administration, with associated inefficiencies. There is a wide degree of consensus amongst different political and health-related organisations that this can best be addressed by unifying the myriad of public sector health departments into a single National Health Service. While there would be overall policy formation, strategic planning and health service coordination at the national level, there would also be significant decentralisation of responsibility to the provincial and district levels. The major challenge for a future “Government of National Unity” will be to redress the gross inequalities in the current health system. It will need to investigate possible ways of resolving the maldistribution of resources between the public and private sectors, to reduce geographical and “racial” disparities in health service provision, and to address the financial barriers to obtaining health care for lower income groups. As there will be competing claims on the limited resources that will be available to the newly elected democratic government, alternative source of finance for health services are currently being investigated. These include increased excise on tobacco and alcohol products, increased user fees at public sector hospitals for patients who have medical insurance cover, and the possible implementation of a National Health Insurance system. The latter option is supported by many groups in South Africa, and is seen as an important mechanism for addressing the current cost spiral in the private health sector. There are unlikely to be any easy or short-term solutions to the many problems confronting the South African health system. However, if the political will to achieve a just and equitable health system is sustained, significant gains can be made during this transitional period.