Health Care Reform in the New South Africa

Abstract

HE social transition that must follow the political transition in South Africa will pose major challenges for many decades. The need to reduce inequities is undisput-ed. However, the means of effectively and sustain-ably achieving this reduction are less clear, especially in the face of rapid population growth and minimal additional resources in an economy that is growing less rapidly than hoped for by the new government. Health care reform exemplifies the many challenges facing South Africans. Profound shifts in thinking about the social forces influencing health and dis-ease underlie the shift from the conventional bio-medical model of health care to the primary health care approach within a fixed or even diminishing public health budget. The move toward a primary care approach in South Africa is not the same as a shift in emphasis toward primary care in highly in-dustrialized nations. An attempt is made here to provide some insight into this process by describing the dilemmas facing health care reform in South Af-rica and the threats to academic activities that will be central to future progress. In the 1930s it was recognized that health care could not be provided for the growing and diverse South African population by allowing entrepreneurial medical services to develop haphazardly. The plea for a national health service by the president of the Med-ical Association of South Africa in 1931 was echoed by the government-appointed National Health Serv-ices Commission in 1944. The rejection of this pro-posal, the subsequent election of a Nationalist gov-ernment in 1948, and the institution of apartheid were associated with the development of a health service characterized by racial discrimination, frag-mentation, poor coordination, duplication of servic-es, and a predominant focus on hospital-based care rather than primary care. 1-3 Privately financed medicine flourished, providing excellent primary and community-level care for pa-tients (predominantly white) who had health insur-ance through more than 200 private insurance com-panies. Tertiary services, which were largely confined to government-financed academic hospitals, were available free of charge to the indigent as well as to those with private insurance. As a result of this focus on hospital-based care, academic medicine thrived T