Skip to main content
Article thumbnail
Location of Repository

Policy Brief: How pro-poor is the South African Health System?

By Ronelle Burger


This chapter investigates how effective recent changes in the South African public health care system have been in transforming the inequitable system inherited from the apartheid-era government. How has post-apartheid budget reallocations, decentralisation, the elimination of primary health care user fees and expansion of the network of clinics changed the incidence of spending and the quality of services provided? Have these changes benefited the poor? The results from research conducted indicate that the distribution of health spending on hospitals and clinics is driven by utilisation patterns. The decision by the affluent to opt-out of the public health system means that the most affluent receive a dramatically smaller proportion of the budget than the rest. There is, however, not much evidence of pro-poor targeting for the rest of the income distribution. However, in terms of spending equity, South Africa compares well with other developing countries. It is clear that health services have become more accessible and more affordable for the poor. Yet, the government is still far from achieving universal access and the desired degree of equity. In addition, there are concerns regarding the quality of services provided by public sector clinics and hospitals. Dissatisfaction among users of public sector services has increased and complaints include long waiting times, staff rudeness and problems with the availability of drugs.Fiscal incidence, South Africa, health

OAI identifier:

Suggested articles


  1. (2003). A new face for private providers in developing countries: what implications for public health?
  2. (2003). Analyzing the Incidence of Public Spending. In: Bourguignon F, Pereira
  3. (2003). and Lindelow
  4. (2000). Expenditure Incidence in Africa: Microeconomic Evidence.
  5. (2003). General Household Survey
  6. (2006). give more detail on the available surveys as well as the assumptions. Arguably, the most important assumption is equal unit costs (discussed in a subsequent section).
  7. (2006). Have pro-poor health policies improved the targeting of spending and the effective delivery of health care in South Africa? Available from:
  8. (1999). How equitable is public spending on health and education? Available fr i This paper draws on work with Christelle Swanepoel. For more details regarding the calculations reported here, consult Burger and Swanepoel
  9. (2000). Income and Expenditure Survey
  10. (1997). Inequity in the South African health sector: Input chapter for the Poverty and Inequality Report. Cape Town:
  11. (2000). Labour Force Survey
  12. (1995). October Household Survey
  13. (1999). Patient choice of primary health care provider. South African Health Review. Durban: Health Systems Trust.
  14. (1993). Project for Statistics on Living Standards and Development. South African Rich &Poor: Baseline Household Statistics. Cape Town:
  15. (2004). The Performance of different models of primary care provision in Southern Africa.
  16. (2005). The utilisation of curative healthcare in Mozambique: Does Income Matter?
  17. (2006). xiii The method for calculating the user costs is quite involved and outlined in detail in a footnote of Burger and Swanepoel
  18. (1993). xviii For the calculation based on the PSLSD
  19. (2000). Yaqub

To submit an update or takedown request for this paper, please submit an Update/Correction/Removal Request.