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US President Barack Obama said that increasing income inequality is the "defining challenge of our time". Although he was addressing an American audience at the time, inequality is a global issue, and one that is particularly pressing in South Africa. In 2011 the World Bank ranked South Africa as the world's most unequal country in terms of income disparity with a GINI coefficient of 65 (0 indicates total equality while 100 indicates complete inequality).
"South Africa is one of the most unequal societies in the world. Although our gross national income falls within the range of middle-income countries, it is not a good indication of income distribution, as the country experiences extremes in terms of poverty and wealth," said Prof Lilian Dudley, who heads the Faculty of Medicine and Health Sciences (FMHS)'s Centre for Health Systems and Services Research and Development (CHSSRD).
The income disparities caused and maintained by the former apartheid system follow mainly racial lines. Although apartheid was abolished in 1994 and South Africa is now enjoying its 20th year of democracy, data shows that the income gap between rich and poor has actually increased over the last two decades.
The inequalities in South Africa's socio-economic landscape are amplified by the skewed distribution of health resources in the country, with a disproportionately high concentration of resources in the private sector and metropolitan regions, explained Prof Ronelle Burger from Stellenbosch University's Department of Economics.
South Africa's health system is polarised with around 16% of the population covered by medical insurance and using private health care almost exclusively, while the uninsured 84% mostly rely on public facilities.
In 2010 there were 6 775 medical practitioners working in the private sector (around one doctor per 1 200 population), and 11 309 in the public sector (around one doctor per 3 700 population). For medical specialists the numbers were even worse with 5 410 working in the private sector in 2010 (one specialist per 1 500 population) compared to only 4 442 being employed in the public sector (one specialist per 9 500 population).
The unequal division of health resources is not limited to medical staff and can be seen throughout the whole health system, from the amount of beds available to the availability of medication and equipment.
"The allocation of resources in the two systems also determines the value that is placed on a life. A prime example is the different resuscitation rules in public and private hospitals. Babies born at 26 weeks in a public hospital will not be resuscitated because the lack of resources makes it difficult to keep the baby alive, whereas in a private hospital, babies are often resuscitated at 26 weeks," said Burger.
"There will always be some inequality, but the polarisation between the two systems is extreme with very little on offer for the so called middle market," said Burger. Compounding the health problem for South Africa's poor is that in addition to low levels of resources, the burden of disease and disability is also much greater among lower socio-economic groups.
"At present, South Africa represents a classic example of the inverse care law; the lowest socio-economic groups bear the largest burden of ill health but have the lowest level of health service utilisation and derive the least benefits from service use," Akazili, Ataguba and McIntyre wrote in a 2011 article published in the International Journal for Equity in Health.
"South Africa's leading burden of disease is dominated by diseases related to poverty," said Dudley. "TB and HIV are the biggest causes of ill health and death in adults, while diarrhoeal disease and pneumonia are the leading causes of ill health and death in children. And these diseases are all highly preventable and related to poverty."
At the same time the country is also experiencing an increase in non-communicable diseases, or so-called diseases of lifestyle such as diabetes and hypertension, which are also disproportionately affecting poorer populations, according to Akazili et al.
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Photo: Prof Lilian Dudley