The majority of South Africans, 71.6%, rely on the public health sector for their regular care.
With only 14% of South Africans covered by medical aid, new government data reveals a deepening crisis in healthcare affordability, where race, geography and income determine who gets treated and who goes without.
South Africa’s healthcare system is fracturing along familiar lines.
Fresh data from Statistics South Africa’s (Stats SA) Income and Expenditure Survey 2022-23, released on Thursday, lay bare the scale of inequality in how households access and pay for medical care.
The report features medical aid contributions running into the billions, while millions of families pay entirely out of pocket for basic health services.
Additionally, the survey, conducted between November 2022 and November 2023, found that households collectively spent R103.5 billion in medical aid contributions during this period, yet only 14.1% of the population holds medical aid coverage.
The remaining 85.9% are entirely uncovered.
The medical aid gap is wider than most realise
The racial disparity in coverage is stark. Nearly 70% of white South Africans hold medical aid, compared to just 7.9% of black African people, well below the national average.
The Indian/Asian population sits at 42.2% coverage, with Coloured South Africans at 17.7%.
Statistician-General Risenga Maluleke noted that the findings were intended to directly inform planning.
“The information will assist programme managers in the planning of health-related programmes and inform policy making in the health systems of South Africa,” he said.
Young adults aged 20 to 24 are the least-covered age group, at 7.8% within their cohort, while coverage rises sharply with age, reaching 31.8% among those aged 75 to 79.
This pattern shifts when broken down by race: black African people dominate coverage in younger age groups, while white South Africans hold the majority of coverage from age 55 upwards.
ALSO READ: 2026 medical aid contribution increases: DHMS vs the rest
Western Cape leads medical aid coverage, Limpopo trails behind
Medical aid coverage varies significantly across South Africa’s nine provinces, with the Western Cape recording the highest coverage at 23.8%, followed by Gauteng at 19.6%.
Both provinces sat well above the national average of 14.1%.
Northern Cape and Free State sat close to the national average at 14.3% and 14.0%, respectively.
Meanwhile, the Eastern Cape recorded 10.2% and the North West 9.6%, both below the national benchmark but still in double figures.
KwaZulu-Natal, despite being one of the country’s most populous provinces, recorded coverage of just 9.1%.
Mpumalanga sat at 8.4%, while Limpopo records the lowest medical aid coverage in the country at 7.3%.
Stats SA noted that “a higher medical aid coverage was recorded in Western Cape, Gauteng, Northern Cape and Free State, while Limpopo and Mpumalanga were the least covered by medical aid.”
The provincial disparities mirror broader patterns of economic inequality and urbanisation across the country.
Urban settlements recorded coverage of 19.1%, above the national average, while traditional settlements record just 3.9%.
Farm settlements sit at 12.1%, also below the national average.
Men contribute more, but women outnumber them in coverage
Male-headed households contributed R71.8 billion toward medical aid – more than twice the R31.7 billion contributed by female-headed households – despite females holding slightly higher coverage rates (14.3% versus 13.9%).
On average, male-headed households paid R27,662 annually, compared to R20,875 for female-headed households.
White households contributed the most in absolute terms at R48.1 billion, followed by black African households at R40.4 billion.
However, despite being the second-largest contributor overall, black African households paid the lowest average contribution of any group at R18 561, revealing how sheer numbers mask per-household financial strain.
Stats SA noted that “even though black African-headed households were the second largest contributors to medical aid expenditure, on average, they contributed the least to medical aid than any other population group.”
Gauteng households led the province’s contributions at R36.1 billion, with the Western Cape second at R28.3 billion.
On a per-household basis, though, the Western Cape tops the country at an average annual contribution of R36 009.
ALSO READ: Prof Glenda Gray: On the front line battling pandemics
Out-of-pocket spending hits hardest where coverage is lowest
Beyond medical aid, households spent an additional R31.5 billion out of pocket on health services, averaging R1,481 per household, representing just 1% of total household expenditure.
The wealthiest quintile accounted for R22.5 billion of that total, or 71.3%, spending an average of R5 285.
The poorest quintile spent only R674 million in total, averaging R158 per household.
Stats SA’s report shows that the burden falls disproportionately on those already most vulnerable.
Poor households – those living below the lower bound poverty line – spent just R1.5 billion on health with an average of R316, while non-poor households spent R30 billion at an average of R1 828.
Medicines accounted for R11.2 billion of out-of-pocket spending, split roughly between prescription (R5 billion) and non-prescription purchases (R4.5 billion).
Assistive products for vision, such as spectacles, accounted for R3.5 billion, while outpatient curative and rehabilitative services cost households R3.2 billion.
Despite the pressure, 87.1% of households reported being able to afford their prescribed medication. Still, nearly one in ten, 9.6%, said they could not.
Public clinics carry the country, but the system is buckling
The majority of South Africans, 71.6%, rely on the public health sector for their usual care, with public clinics serving 65.7% of the population.
Only 1.4% use private clinics, and 1.8% private hospitals.
Stats SA framed the findings within the country’s broader reform ambitions.
It noted that the proposed National Health Insurance is “geared towards alleviating these costs, but the public health system is burdened by budget constraints and staffing challenges, while public healthcare institutions report a critical shortage of doctors and nurses, while many qualified healthcare professionals remain unemployed.”
READ NEXT: These are the top causes of death in South Africa in 2023
