GDP: 351.4 Billion USD1
Health Expenditure (% of GDP): 8.25%2
  • Population: 5.1 Million
  • Housing: 66.3% Urban, 33.7% Rural


The current state of the health system is due to many epidemics and policies from the country’s eras such as colonial subjugation, apartheid, and the post-apartheid period.14 South Africa has had racial and ethnic discrimantion laws beginning in colonial times that have dominated the culture of the country until recent decades.5 There was a major attempt to restrict black individuals from urban areas to the reserves during this time. Disparities in healthcare also arose because there was one doctor for every 308 white people compared with one doctor for 22,000 to 30,000 black people in the reserves. Furthermore, the urban black population grew 94% between 1921 and 1936.There was racial segregation of urban areas as well because the reservation of land was mostly for white people. The lack of proper housing and land led to the creation of overcrowded, unsanitary hostels and slums in the urban black areas. From 1948, the National Party came to power and created the policy of apartheid, which consolidated the political exclusion, economic marginalization, social separation, and racial injustices of the last 300 years. The system determined where a person could live, work, and go to school, whom they could marry, whether they could vote, and the resources allocated to education, health care, and pensions based on their racial classification. The laws were reinforced by state control and repression. Black people were denied citizenship in South Africa and continued to be forcibly removed to the rural labour reserves. In 1952, a segregated medical school was established for black students.14 In 1994, Nelson Mandela became the first black president and ended apartheid policies. Legal discrimination ended and more favorable policies towards the black populations. However, apartheid policies left an outstanding aftermath that still causes detrimental outcomes for vulnerable populations. 
Since the 17th century, South Africa has faced a significant burden of epidemics such as poverty, smallpox, measles, malaria, and others. To combat these illnesses, the country relied on traditional healers, Europeans trained doctors, missionaries, and other health providers. The 19th century brought epidemics of syphilis, tuberculosis, bubonic plague, and cholera, among others. In 1807, the first health legislation created the Supreme Medical Committee to oversee all health matters. There were expansions of health practices throughout the colonies but it wasn’t until 1883 that the first public health act was passed in response to the epidemics. Public health began to take priority during this time with the first unionwide public health department established in 1919. Community health centers began in 1945 and were the foundation of community-based primary health care and increased access to health for many. Most recently, South Africa experienced one of the highest burdens of HIV/AIDS and continues to be detrimental today. There was complete government denial which caused an extremely slow action towards an HIV/AIDS response until the early 2000s. An ambitious program was introduced to provide antiretroviral therapy to all patients.14 Spending on HIV increased at an average annual rate of 48.2% between 1999 and 2005.11 
Private health care has existed in South Africa since the 19th century but was funded by out-of-pocket payments until 1889. That year, medical schemes were introduced to meet the healthcare demands of white mine workers. These plans were exclusive to the white population until the late 1970s when black people were allowed to access this health coverage, however cost was a major barrier to obtaining it. The private sector grew exponentially throughout the 20th century and redirected medical resources to it. By 1980, 40% of doctors worked in the private sector and that number grew to over 60% by 1990.14 


South Africa’s constitution guarantees every citizen access to health services through the public and private health sectors.8 The country is divided into nine provinces and each has a Department of Health that participates in health delivery, along with local Departments of health responsible for health promotion and preventative services. Low quality public health care is available to all citizens for free with no formal health insurance plans.5 This public health system is divided into three tiers of health services. Primary care facilities are meant to be the first point of contact for patients and provide an initial assessment of the patient. There are over two thousand primary care clinics and are mostly staffed with nurses providing community health services. District hospitals are the second tier and this is where patients can be tested and have minor procedures performed. Tertiary hospitals are bigger in terms of infrastructure and have advanced technologies for major surgeries. Specialists are required at these hospitals because patients with serious conditions are treated there.9 Most of the South African public health system is funded by a National Revenue Fund, which collects payments made to local, provincial, and federal governments. There is a decentralized distribution of funds from federal to local municipalities, giving local public health agencies independence over allocation of funds.5 
To ameliorate the lack of quality and access to care, the government plans to establish the National Health Insurance in 2026. It intends to ensure access to all citizens and residents of South Africa to quality health services provided by both the public and private sector, regardless of socioeconomic status. It would be a social health insurance in that it enforces contributions from employers and employees to partially fund the system. South Africans would have federal government-sponsored plans to choose from that will pay directly for health services from all providers. The aim of the program is to encourage the wealthiest to pay into the public system and incentivize them to use public health services.5,12  
The private health sector in South Africa accounts for the largest share of health expenditures through out-of-pocket-payments and medical schemes. There are around 200 private hospitals throughout the country which can only be accessed with private insurance or self-pay. Only 18% of the local population regularly use private providers and despite being much smaller than the public sector, it accounts for about half of expenditures. About 79% of doctors work privately, leaving only 21% of doctors for the public sector.13 The distribution of healthcare resources is inequitable because it disproportionately favors private health care. There are over 120 medical schemes that historically excluded black South Africans until 1970 and still mostly cater to wealthier demographics.9,10 Medical schemes vary by occupation and the capacity of people to afford them. The schemes requires members to pay copayments and for services not included in the benefits package.10 Only 16% of the population has a medical scheme because the cost is still a barrier to a majority of South Africans.10,11 About 73% of white individuals are members of a medical scheme, 52% of Asian individuals and only 10% of black Africans, indicating a clear racial disparity in private coverage.12
South Africa is faced with challenges that have been detrimental to the health system. The country has the largest HIV/AIDS epidemic in the world. South Africa has 0.7% of the world’s population, yet accounts for 17% of the global burden of HIV infections.11 This continued epidemic has forced the health system to focus on lowering prevalence and incidence of HIV/AIDS. Approximately 6.5% of health expenditures is used on services for HIV/AIDS and on average, the US spends $1.5 billion dollar for HIV/AIDS programs.5 South Africa also faces workforce shortages in the health system. Medical schools have an annual output of medical graduates ranging between 1200 and 1300, which is inadequate for the population size. The government had tried to improve this issue by recruiting doctors from Cuba in a government-to-government agreement. There are also government policies that manage the health workforce, for example, the legal requirement for health professionals to register with their respective council upon graduation.5,8 Despite these efforts, the demands for health professionals are not met.


  • Fertility Rate: 2.4 live births per woman  
  • Life Expectancy (Female, Male): 68, 62 
  • Infant Mortality Rate: 23.6 deaths per 1,000 live births  
  • Child Mortality Rate: 30.7 per 1,000 live births
  • Maternal Mortality Rate: 119 deaths per 100,000 live births3   
  • Black: 80.9%
  • Mixed: 8.8%
  • White: 7.8%
  • Asian/Other: 2.5%
  • 0-14 years: 27.94% (male 7,894,742/female 7,883,266)
  • 15-24 years: 16.8% (male 4,680,587/female 4,804,337)
  • 25-54 years: 42.37% (male 12,099,441/female 11,825,193)
  • 55-64 years: 6.8% (male 1,782,902/female 2,056,988)
  • 65 years and over: 6.09% (male 1,443,956/female 1,992,205) (2020 est.)


  1. South Africa.
  2. South Africa Demographics. (n.d.).
  3. Maternal mortality ratio (modeled estimate, per 100,000 live births) - South Africa. (n.d.). 
  4. Health Policy Project. (2016, May). Health Financing Profile - South Africa. 
  5. Modisakeng, C., Matlala, M., Godman, B., & Meyer, J. C. (2020, March). Medicine shortages and challenges with the procurement process among public sector hospitals in South Africa.   
  6. Conservation. (n.d.).  
  7. South Africa Age structure. (n.d.). 
  8. Minumum Data Sets for Human Resources for Health and the Surgical Workforce in South Africa's Health System. (2015, September). 
  9. Sopitshi, A., & Van Niekerk, L. (n.d.). County Profile: South Africa. 
  10. Health Policy Project. (2016, May). Health Financing Profile - South Africa. 
  11. Mayosi, B. M., & Benatar, S. R. (2015, January 01). Health and Health Care in South Africa - 20 Years after Mandela: NEJM.  
  12. Health. (n.d.). 
  13. Healthcare in South Africa: A guide for expats. (2021, January 07).  
  14. Coovadia, H., Jewkes, R., Sanders, D., & McIntyre, D. (2009, August 25). The health and health system of South Africa: Historical roots of current public health challenges. 

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