Health care capacity and allocations among South Africa's provinces: Infrastructure-inequality traps after the end of apartheid

Objectives: We assessed the determinants of health care funding allocations among South Africa's provinces and their effects on health care from 1996 through 2007. Methods: We performed multivariate regression of funding allocation data against measures of disease burden and health system infrastructure by province. Results. Disease burden was increasingly negatively correlated with funding allocations and explained less than one quarter of the variation in allocations among provinces. Nearly three quarters of the variation in allocations was explained by preexisting hospital infrastructure and health care workers. The density of private hospitals in the preceding year was associated with greater government allocations (bprivate=0.12; 95% confidence interval [CI]=0.08, 0.15), but public hospital density in the preceding year was not (bpublic=0.05; 95% CI=- 0.02, 0.11). Greater allocations were associated with a higher number of doctors (b=0.54; 95% CI=0.34, 0.75) but fewer nurses (b=-0.37; 95% CI=-0.72,-0.25) in the same year. Conclusions. Regions with a greater capacity to spend funds received more funding and created more infrastructure than those with greater health needs. Historical infrastructure inequalities may have created an infrastructure- inequality trap, in which the distribution of funds to those with greater "absorptive capacity" exacerbates inequalities.