The challenges of pursuing private health insurance in low- and middle-income countries: Lessons from South Africa

Abstract

South Africa's apartheid history of legislated discrimination on the basis of race has left a legacy of massive income inequalities-with, at 0.63 in 2011, one of the highest Gini coefficients in the world (World Bank, 2017)-and inequalities in access to social services. It has also left an indelible imprint on the health sector, where private health insurance was developed to serve white workers, whereas the public health sector served the majority black population and lower-income whites. The use of the terms African, Coloured, Indian (and the combined group black) and white indicates a statutory stratification of the South African population in terms of the former Population Registration Act. The use of these terms does not imply the legitimacy of this racist terminology, but is necessary for highlighting the impact of former apartheid policies on the health system. Since the first democratic elections in 1994, there has been considerable commitment to addressing these inequalities. However, progress has been limited: income inequalities have in fact been growing and inequalities within the health sector are increasingly related to class rather than race.