Putting equity in health back onto the social policy agenda: experience from South Africa.

Over the past decade, international health policy debates have been dominated by efficiency considerations. There has been a recent resurgence of interest in health equity, including consideration of the notions of vertical equity and procedural justice. This paper explores the possible application of these notions within the context of South Africa, a country in which inequities in income and social service distribution between 'racial' groups were systematically promoted and entrenched during four decades of minority rule, guided by apartheid and related policies. With the transition to a democratic government in 1994, equity gained prominence on the South African social policy agenda. Health equity has been awarded a particularly high priority, not least of all because the health sector is seen as vehicle for achieving rapid equity gains. In addition, many of the other equity-promoting social sector policies (such as improved access to housing and water and sanitation services) have been motivated on the basis of their potential health equity gains. The South African experience since 1994 provides useful insights into factors which may facilitate or constrain health equity progress. In particular, the constitutional entitlement to health and civil society action to maintain health equity's place on the social policy agenda are seen as important facilitating factors. Certain health sector programmes have also been developed which are intended preferentially to benefit those who have been historically dis-advantaged, and which thus support vertical equity goals. However, there have been no efforts to promote cross-subsidisation between the private and public health sectors, and initial efforts to promote coherency in social policies (through the Reconstruction and Development Programme) appear not to have been sustained. In addition, macro-economic policies (particularly the highly ambitious budget deficit reduction targets of the government) are likely to undermine some of the equity-promoting social policy initiatives. Most importantly, the potential inter-relationship of vertical equity and procedural justice goals has not been adequately recognised. As a result, and despite policy rhetoric, this paper concludes that health equity goals are critically dependent on the central involvement of the dis-advantaged in decision-making about who should receive priority, what services should be delivered and how equity-promoting initiatives should be implemented.