While the South African government has established a larger healthcare budget than some of its sub-Saharan Africa counterparts, that funding is widely dispersed and therefore largely diluted by the time it reaches the country’s 49 million people.

The structure of healthcare around the globe varies as widely as the health issues facing the citizens of every country. Funding for health care systems is equally variant, and largely dictated by both the economic and developmental status of each country. Developed nations are generally able to offer a wider scope of services at higher subsidized rates

Because of the lack of healthcare infrastructure, developing countries suffer disproportionately from diseases and other public health problems. South Africa, for instance, is home to over 5.7 million people living with HIV⁶, and was ranked 175 out of 191 in the 2000 WHO healthcare survey. The recent global economic crisis limits the depth of resources allocated by South Africa to any one government sector, and health care is no exception. As Dr. Thembi Xulu, Medical Director of Right to Care, explains, “[most] African governments have not been putting enough [funding] towards their health budgets. African heads of state met in Abuja in 2001 and all pledged to commit at least 15% of national budgets to health [but] that is not happening yet. South Africa is spending 9.1% of its budget on health but it’s still not enough to meet the country’s needs because we cannot even start implementing the much needed national health insurance.” In the case of many developing nations – South Africa included – this deficit is reduced with the help of non-governmental organizations (NGOs) and foreign government aid. One such NGO is Xulu’s Right to Care, one of the largest NGOs to provide healthcare to South Africans affected with HIV/AIDS, tuberculosis (TB), and other poverty-related diseases.

While the South African government has established a larger healthcare budget than some of its sub-Saharan Africa counterparts, that funding is widely dispersed and therefore largely diluted by the time it reaches the country’s 49 million people. First, the healthcare budget is divided amongst the nine provinces of the country. Prior to 2004, the healthcare allocation amongst the provinces was equal, resulting in an emphasized financial divide between the rural and urban areas of the country. Starting in 2004, the government allocates resources on a sliding scale based on province need. As a result, “provinces that have high economic activity and [available] jobs tend to be overpopulated and end up getting quite a significant share of the budget,” according to Xulu. However, the situation arises that “once the money is inside the provinces, the provinces have autonomy to decide” which province-specific health programs are funded [and] in what proportion”, says Xulu. Provinces also individually decide how they monitor standards of disease treatment and patient quality of care since there is no countrywide health monitoring and evaluation system established by the national government. This autonomy creates a problem of migration between the provinces since sick individuals seek the best care, overpopulating and straining the resources of hospitals that provide such care.

To alleviate some of this strain, NGOs aid in the operation of government-funded clinics and hospitals. A significant number of South African healthcare NGOs focus on providing care to patients with HIV, AIDS, TB, and other poverty-related diseases, since about 60% of hospital admissions are related to these diseases. Similar trends are seen in other developing nations around the world. These NGOs operate independently, but the national government often provides partial funding. In 2006, the South African government allocated over $8 million in grants to such NGOs. Developed nations also aid the NGO efforts. Under President George W. Bush, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) was established specifically to assist developing nations in combating HIV, AIDS and TB by partially funding NGOs focused on these diseases. In the case of South Africa, the government pays 83% of the costs associated with running programs like Right to Care, and funds from PEPFAR cover the remaining 17%. Xulu says “it’s quite a nice balance in terms of sustainability beyond the donor funding” but adds that PEPFAR does not extend to all countries, so South Africa’s situation is somewhat unique.

Right to Care is one of the HIV, AIDS, and TB-focused NGOs Xulu refers to as the “big five players” who get top funding by PEPFAR to service citizens across South Africa. The other four are the Foundation for Professional Development (FPD), the Reproductive Health and HIV Research Unit (RHRU), BroadReach, and the Perinatal HIV Research Unit (PHRU). Since the government contributes the majority of the funding for these NGOs, the NGO services are incorporated into the government’s health infrastructure rather than existing as alternative health care providers. For instance, Right to Care doesn’t own any clinics – employees work within the South African Department of Health clinics.

Funding for NGOs isn’t the only way in which South Africa relies on foreign aid to support its healthcare system. The South African government actively recruits doctors from Tunisia, Cuba, and Iran to supplement the doctor shortage that persists.^3,4 The approach is very practical, and is also used by the NGOs. As Xulu explains, “when doctors from Tunisia or Cuba [or Iran] come in, once they’ve met the certification requirements from the government’s perspective and are registered on the health professions council, nothing stops [Right to Care] from employing them.”

When asked what she would emphasize if given the opportunity to develop the South African healthcare system from scratch, Xulu sees access to services and quality of care as most important. Remaining loyal to her cause, she says she would advocate “integrating HIV care into all health systems… Many units within the healthcare system functions in silos. [We need to] integrate healthcare so that it’s [under] one provider – under one roof – making it convenient for our patients.” If money were not an issue, Xulu’s healthcare system suggestions stem from a saying she recalls from her graduate school days: “just before the HIV epidemic was at its peak, we used to say ‘poor people are so poor, they can’t even afford to get sick,’ because even when they were sick they had to go to work because they were poor. But now the poorest of the poor have HIV. They’re dying, so now they are the sickest of the sick and they can’t work because they are sick… The only way to change that is to bring services to the people, so national health insurance would be big on my agenda.”