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The National Health Insurance (NHI), for which membership will be compulsory, is a funding scheme that aims to address healthcare inequity in South Africa. The scheme will do this by creating a fund that the government will use to buy healthcare services at set fees from accredited public and private health providers. The NHI has not yet been legislated — the health department is hoping to have the NHI Bill approved by parliament by the end of 2022.

HomeSpecial ReportsNational Health InsuranceInequality kills: How race, money and power affect who survives COVID

Inequality kills: How race, money and power affect who survives COVID

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  • Researchers analysed data from 440 000 COVID patients. The results showed that inequality in South Africa still affects who lives and who dies. 
  • The data reveals that even though Black Africans were more likely to die of COVID than white people, they were less likely to get an ICU bed. 
  • Plus, people admitted to private hospitals had a better chance of surviving than those who went to state facilities. 

COMMENT

Pandemics are magnifying glasses that reveal what society looks like. 

They expose long-existing inequalities and demonstrate how factors such as where people were born, where they live, what job they do, and how much access they have to money and power, interact to influence their chances of access to healthcare — and survival.  

In South Africa, COVID-19 has, for instance, shown us that the country’s history of racial inequalities, even after almost 30 years of democracy, still affects who lives or dies, who gets an intensive care (ICU) bed, or who has access to lifesaving oxygen or ventilation when they end up in hospital.  

We know this from analysing the data of almost 440 000 patients — collected between March 2020 and January 2022 — from DATCOV, a system that was created during the pandemic, and which allowed for public and private COVID-19 hospital admissions to be recorded in the same database. 

We looked at demographic information such as age, sex and race; risk factors for falling seriously ill with COVID, such as age, obesity, diabetes and hypertension, and compared the data to the type of treatment someone received and the outcome thereof. 

As researchers, we wanted to answer the question: “Why are Black Africans, coloured and Indian people, seemingly, being disproportionately affected by COVID-19?”

This is what we found

  • People of colour (Black Africans, Indian and coloured people) had a higher risk of dying of COVID-19 than whites;
  • People admitted to public hospitals were more likely to die of COVID-19 than those with beds in private hospitals;
  • Black Africans admitted to public hospitals had a lower chance than white people of getting an ICU bed or being ventilated — despite having a higher risk of dying;
  • Black African, coloured and Indian private hospital patients had a higher chance of being treated in ICU or ventilated;
  • Of patients who died of COVID-19 in hospital, 10% in the public sector were treated in ICU, compared to 60% in the private sector.

What do these results mean and tell us about South Africa?

Our findings tell South Africa’s story of inequality and the consequences thereof on health outcomes. 

We argue that a legacy of long-standing inequalities has resulted in structural discrimination and exclusion to healthcare based on race. 

There is little conclusive evidence that genetic or biological reasons alone can explain the racial and ethnic differences in people’s likelihood to get infected with SARS-CoV-2 (the virus that causes COVID-19) or die of it. In fact, attributing poor clinical outcomes in vulnerable race groups solely to genetics and biological differences has historically been responsible for marginalising their health needs. 

Rather, we need to look at the impact of structural inequalities such as unemployment, poor housing, low household income, food insecurity and environmental hazards, as well as social factors such as racism and oppression, to find the answers. 

South Africa is the country with the highest level of income inequality in the world. Black Africans, people without jobs, those who are less educated, and female-headed households are the poorest people in the country. Our study showed that people of colour and people with lower incomes (we used the type of health facility used as a proxy for someone’s income) had a higher risk of dying of COVID-19 and a lower chance of being treated in an ICU or being intubated. 

Why?  

Because how much money you earn influences the quality of health services that you have access to, whether you can afford transport to a health facility, whether you live in a crowded or spacious place, how much food you have and how likely you are to live with another condition, such as diabetes, obesity, hypertension, HIV or TB, that make you more likely to get very sick with COVID-19.  Your salary is, of course, also closely related to the type of job you do, which in turn, determines how exposed you are to contracting an airborne virus such as SARS-CoV-2. 

Our data shows that most COVID-19 hospital admissions were among Black African, coloured and Indian people of working age. 

How inequality makes Black people more likely to get infected with SARS-CoV-2  

South African blood service data shows that SARS-CoV-2 infection is consistently higher among Black African individuals than the rest of the population. 

This is because their socioeconomic status makes them more likely to be exposed to the virus: poorer people tend to use public transport (as opposed to private cars with only a few passengers), they often live in multigenerational households with little space for social distancing and have manual labour jobs that make it impossible for them to work from home during periods when infection rates are high. 

But what happens after someone gets infected, in other words, how likely they’re able to access quality healthcare to treat their infection, also plays a crucial role in their survival. 

South Africa has a two-tiered health system where in 2019, 40% of all spending on healthcare in the country was in the private healthcare system, which only serves 27% of the population. Higher spending buys more medical expertise, specialised hospitals, sophisticated technology and equipment and advanced and expensive medication. 

Only one out of 10 Black Africans belong to a medical aid  

But in South Africa only just over 15% of the population can afford medical insurance, the rest have to rely on under-resourced state hospitals and clinics or pay for private healthcare in cash. Our study showed Black Africans were less likely to be admitted to private hospitals — and that Indian and white people had a higher chance of accessing a private hospital bed. They therefore also had a higher chance of survival, as our results reveal that public patients were more at risk of dying from COVID-19 than private patients. 

When we look at the race breakdown of medical aid coverage in the country, it’s clear why Black Africans were less likely to end up in private health facilities: most can’t afford medical insurance, which you need to cover the cost of such care. A 2018 general household survey conducted by Statistics South Africa showed that 10% of Black Africans have medical aid, 17% of coloureds, 52% of Indians and 73% of whites. 

It was therefore not surprising that in the private sector people of colour were not deprived of being treated in ICU or ventilated. But of concern was that in the public sector, Black people were less likely to be treated in ICU or ventilated, compared to whites. The inequality could be due to Black patients more likely accessing care in rural district hospitals that had few ICU or ventilators available. 

A study in Brazil also revealed whites were more likely to be admitted to ICU than people of colour. In South Africa, 47% of individuals in the 2018 general household survey reported facing challenges in access to health services. Black South Africans, rural residents, the less educated, the unemployed and the poor were most likely to report such difficulties and struggled with issues of long travel times to the nearest healthcare facilities or inconvenient operating hours.

What now? 

Our study shows how important it is to collect data on socioeconomic status and race, alongside age and sex, to identify the groups of people in a population most likely to get infected and fall ill with COVID-19. Without doing this, we won’t know how to design interventions that work best for vulnerable populations. 

But our study also confirms how crucial it is for health resources between the public and private healthcare systems to be redistributed so that access to healthcare is more equal in the country. Healthcare is a human right built into our Constitution, and the quality of care that you receive shouldn’t have to depend on how much money you can pay for it. The country’s proposed National Health Insurance scheme is one way of addressing this — but it will only work if access to quality healthcare is at the heart of its planning.  

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Waasila Jassat leads DATCOV, the national COVID-19 hospital surveillance system.

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Cheryl Cohen is associate professor in epidemiology at the University of the Witwatersrand and co-head of the Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases.

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Nicholas Crisp is the deputy director general in the national health department responsible for implementing the country’s National Health Insurance scheme.