RECOMMENDATIONS

Development of a unitary, post-apartheid health system, accessible to the poorest South Africans yet appealing to middle and upper class whites and non-whites as well, should be a high human rights priority. The International Convention on the Prevention of All Forms of Racial Discrimination requires states to eliminate policies that are discriminatory in impact as well as intent.¹ To comply with the Convention, which constitutes the most authoritative statement of international law bearing on state-sanctioned racial discrimination, South Africa will need to transform its public medical services system to greatly reduce racial disparities in access and resource allocation. Incorporation of patients from diverse spheres of South African life within a single health system, funded equitably and administered with an eye toward coordination and consistency in clinical practice, would do much to reduce racial disparities in access to care. To be sure, the wealthiest South Africans, like the most privileged in any society, will be able to buy out of a medical system designed to distribute care equitably to the many. But inclusion of substantial numbers of people from all backgrounds within a unitary system would build mass support for a floor below which the quality of care could not fall—and would foster a more integrated medical culture, with less racial and regional variation in clinical practice protocols.

Such reform is achievable through a variety of market-oriented
and/or government mechanisms, depending on political and ideological preferences. A single, British-style, state-run National Health Service, well enough funded to attract the middle class, would accomplish this, as would reliance on private markets for insurance and/or provision of care,² so long as public subsidies give the poor enough medical buying power to obtain care from private providers now accessible only to whites. Inevitably, reduction of South Africa's huge racial disparities in public medical spending will require retrenchment, particularly in taxpayer support for the tertiary services now provided disproportionately to whites by academic medical centers. The nation will have to strike some difficult balances between pursuit of racial equity and the costs of cutting support for these high technology centers, which have brought a measure of international prestige and economic benefit to South Africa. These and other hard choices about the reallocation of health care resources³ should be made through mechanisms that insure the participation of knowledgeable representatives of all of South Africa's major racial and ethnic groups.

National and provincial legislation can define budgetary priorities in general terms, but the complexity of the decisions to be made will require administrative regulators and managers to fill in crucial details. The current South African state bureaucracy, staffed largely by holdovers from the apartheid era, is ill equipped to perform this task in a manner responsive to the country's multiracial composition. Creative efforts to involve representatives of diverse racial and community groups in local resource allocation decisions will be necessary. In addition to developing substantive guidelines for the distribution of medical resources in the new South Africa, Parliament should specify mechanisms for administrative and regulatory decision-making that mandate the participation of representatives of the country's diverse constituencies.

In addition to the institutional restructuring urged above, South African law ought to clearly proscribe racial disparities in the allocation of public funds to health services⁴ and make discriminatory treatment of patients by hospitals, physicians, and other providers clear cause for professional discipline and other sanctions. Such sanctions should be triggered by segregation of waiting rooms, treatment facilities, etc.; disparities in technical quality of care (e.g. race-linked differences in practice protocols or treatment actually provided); and expressions of race-related disrespect or contempt.

To address the enormous disparity between the racial distribution of South Africa's population and its medical community, robust affirmative action efforts are essential. Affirmative action in clinic, hospital and academic medical hiring, as well as medical school admissions, and academic, emotional, and financial support for black students, is essential. On the other hand, no amount of affirmative action at the level of professional education and hiring can substitute for a national commitment to upgrade early childhood, primary, and secondary school education in black areas, with emphasis on education of girls whose education is essential for family health. The tragic legacy of the "Bantu education" philosophy, which led to gross underfunding and to curricula that emphasized rote training over the critical thinking essential to the preparation of students for higher education, could cast a decades-long shadow over black professional and career development.

NOTES

¹ International Convention on Racial Discrimination, Article 2, 1969.

² The South African Ministry of Health's current plan for reorganizing the nation's health services envisions increased reliance on "contracting out" to private sector providers as part of an effort to develop a higher quality public medical system. Department of Health. White Paper for the Transformation of the Health System in South Africa. Government Gazette, vol. 382, no. 17910. Pretoria, April 16, 1997. For this plan to succeed over the long term, it is essential that quality be raised sufficiently to attract large numbers of middle class South Africans—enough to create a political constituency for preservation of the public system as something more than a separate, inferior program for the poor.

³ Such decisions will include budget allocations between and within government departments and health care institutions, siting of new facilities, salary scales, payment levels and mechanisms for services "contracted out" to the private sector, spending on clinical and basic research, and even allocation of human organs for transplantation.

⁴ Such a prohibition should be phased in over time, perhaps several years, given the enormity of current disparities and the desirability of limiting the institutional disruption that reallocation of public resources will inevitably entail.