The state's disproportionate resource allocation policies at a systemic level in South Africa during the apartheid era resulted in poor quality and inferior services being available to blacks. In the healthcare context, there were treatment delays, drug and bed shortages and, in psychiatric hospitals, black South Africans were refused sheets, made to sleep on the floor and given inferior foods. In many instances, black women were made to leave healthcare facilities immediately after giving birth. While there were resources to provide better care, the apartheid racist policies did not permit this.1
With the establishment of a democratic state in 1994, and the promise in 1996 of the constitutional realisation of socioeconomic rights for all citizens in this country, expectations ran high, in particular, for South Africa's disadvantaged citizens, the majority. Improving the quality of life and freeing every citizen's potential, is established in the Constitution's preamble. While Section 27 requires that the state takes reasonable legislative and other measures within available resources to achieve the progressive realisation of socioeconomic rights, an unqualified, uncompromising right is that of treatment during emergencies –“No-one may be refused emergency medical treatment.”2
The National Health Act,3 promulgated in 2004, provides a framework for a structured and uniform health system in response to the Constitution. Its preamble underscores past socioeconomic injustices and inequities of health services and the need to establish a society based on social justice and fundamental human rights to improve the quality of life for all. The responsibility for the provision of health care is delegated to the Minister of Health.
Eighteen years into democracy, despite South Africa's human rights constitution and laudable legislation, an unjust social order prevails. Poverty is rampant and socioeconomic inequality dominates. A strong private sector allowing access to care for just 16% of the population and an inefficient, poorly managed state healthcare system are the reality of the day. Similar to the apartheid establishment, the state has the resources to provide better services, but fails to do so. However, the reasons for this situation now are both a lack of political will and accountability.
National and provincial government departments and public entities wasted and misused more than R20 (AU$2) billion of taxpayers’ money over the financial year 2010/11, an increase of 12% on 2009/10.4 In the context of healthcare, a barrage of reports have underscored the decline in services. Corruption erodes 10% of all health expenditure in South Africa5 where public resources are siphoned off for personal use, and bribes and kick-backs are accepted by state officials from potential vendors and suppliers. While corruption on the part of state officials is well known, there is relative silence on corruption involving some healthcare professionals who, employed by the state, also engage in private practice during the time they are paid to serve public patients. These professionals repeatedly abandon their public sector responsibilities. They may even use public resources to treat private patients. Corruption is a major and unambiguous contributor to the poor health of South Africa's citizens.
The nature and determinants of health equity are important ethically and politically. Social and economic determinants are powerful contributors towards differential health outcomes and hence, for health reasons, the ethical imperative to reduce social and economic inequalities is underscored. That health is a by-product of justice cannot be denied. Eradicating distributive inequality and ensuring social and economic justice are essential for the health of a country's people. A cumulative experience of social conditions over the course of an individual's life has a major impact on his or her health. The dominant public health problem in South Africa is its widening socioeconomic inequality and as a consequence a system that violates its citizens’ rights to health. While the current health debate focuses on universal coverage and expanding access to health care, it should also include the increasing socioeconomic inequalities as well as income distribution and inequities in education. These social determinants of health are intricately interwoven. Inequality in income invariably results in inequality in education and this directly impacts on health inequality.
A concerted effort is required by all to improve socioeconomic equity and hence, health equity. The major role player in this is positive political will allied to public accountability. Responsibly managing the well-being of its population is at the very core of a capable and good government. Poverty and inequality are bad for health. The state's responsibility towards their permanent eradication must be a national priority.