TOWARDS EQUITY IN HEALTH IN AN UNEQUAL SOCIETY

South Africa is one of the world's most unequal societies and its heal th sector mirrors these inequalities; Since the first democratic elect ions in 1994 the government has been under enormous pressure to dimini sh disparities between population groups in access to health services. This paper documents the structural inequalities in the health sector and discusses the strategic options that are being considered for red ucing them. The overall level of health expenditure is high, amounting to 8.5% of GDP. However, less than 40% of expenditure is on public he alth services and three quarters of that is on acute care hospitals. A more detailed analysis of public health expenditure reveals large dif ferences between census districts. The districts where household incom es are low tend to have fewer public health services. Public health ex penditure per capita was lower than the estimated cost of providing ba sic primary health care in a fifth of districts. The most urgent need is to improve the services likely to reduce excess mortality and morbi dity. This will involve additional funding of primary health service s ervices, particularly in underserved localities. Government cannot inc rease public health rapidly and it will have to re-allocate funding fr om hospitals. The paper discusses options for achieving this, includin g the introduction of social health insurance. It argues that restruct uring the health sector is complex and there is a risk of failure. Gov ernments should base their strategies on a good understanding of the h ealth sector and of the likely impact of different reform options. (C) 1998 Elsevier Science Ltd. All rights reserved.