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Barriers to the equitable funding of primary healthcare in South Africa

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Abstract

Over 25 years after Alma-Ata, available evidence suggests that in low- and middle-income countries (LMIC) the funding and coverage of primary care is still inequitable. This article reviews the progress that has been made towards the equitable funding of primary healthcare (PHC) in South Africa and evaluates barriers to future progress. The South African experience is assessed to consider implications for other LMIC.

The results show that substantial inequities in funding persist (albeit using a narrow definition of PHC). Underlying causes relate to fiscal austerity, the lack of protection of PHC funding, incremental resource allocation and the belief that poorer districts are not able to use extra funds effectively. These results match the experience in other LMIC. Central governments have a critical role to play in lobbying for and protecting resources for PHC, maintaining more control over decentralised resource allocation and building capacity to benefit in poorer areas.

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Notes

  1. 1For additional details on the financing and structure of the South African health system, see Thomas et al.[13]

  2. 2These are compiled 8 months into the financial year and are typically very close to final expenditure figures, which were not available for all districts.

  3. 3All interviewed officials were asked to identify others who could provide useful insights into the resource allocation and budgeting process.

  4. 4The population figures used for the provinces are those without medical aid, as a proxy of public sector dependency, as discussed in section 1.

  5. 5To calculate this allocation, first the deprivation index is normalised by adding a value to all indices such that the lowest index is equal to 1 (in this case, the value is 2.292). The population size of each province is then weighted by the normalised index to emphasise need. The proportion of the budget allocated to each province is directly related to the proportion of the weighted-provincial population. Note that this is a rather crude way of translating the deprivation index into a resource allocation guide. The scale/ratio of the arithmetically adjusted indices will vary with the value added to them. The adjusted indices are not cardinal values. Also resultant weights given to each provincial population are based on arbitrary 1 to 1 weighting of the adjusted index. The authors acknowledge this limitation.

  6. 6Whether the policy was actually freely chosen or effectively imposed is open to debate (see Thomas and Thiede[29]).

  7. 7As countries may not wish to disclose their high military expenditure, this figure may be an underestimate.

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Acknowledgements

The authors would like to thank the Health Systems Trust, the World Health Organization (WHO) and The Valley Trust for their support and funding of the research projects that led to this article. We especially thank Di McIntyre and Lucy Gilson for their support and guidance in the research process and Debbie Muirhead, Deus Mubangizi, Gugu Khumalo and Itumeleng Funani for their roles in data collection and analysis on the Local Government and Health project. We also acknowledge and appreciate the support of the Local Government and Health Consortium.

The authors have no conflicts of interest.

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Authors and Affiliations

  1. Health Economics Unit, University of Cape Town, Cape Town, South Africa

    Stephen Thomas, Okore A. Okorafor & Sandi Mbatsha

  2. Department of Health Policy and Management, Trinity College, Dublin, 2, Ireland

    Stephen Thomas

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  1. Stephen Thomas
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  2. Okore A. Okorafor
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  3. Sandi Mbatsha
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Correspondence to Stephen Thomas.

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Thomas, S., Okorafor, O.A. & Mbatsha, S. Barriers to the equitable funding of primary healthcare in South Africa. Appl Health Econ Health Policy 4, 183–190 (2005). https://doi.org/10.2165/00148365-200504030-00007

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