Barriers to the equitable funding of primary healthcare in South Africa

Over 25 years after Alma-Ata, available evidence suggests that in low- and middle-income countries (LMIC) the funding and coverage of primary care is still inequitable. This article reviews the progress that has been made towards the equitable funding of primary healthcare (PHC) in South Africa and evaluates barriers to future progress. The South African experience is assessed to consider implications for other LMIC. The results show that substantial inequities in funding persist (albeit using a narrow definition of PHC). Underlying causes relate to fiscal austerity, the lack of protection of PHC funding, incremental resource allocation and the belief that poorer districts are not able to use extra funds effectively. These results match the experience in other LMIC. Central governments have a critical role to play in lobbying for and protecting resources for PHC, maintaining more control over decentralised resource allocation and building capacity to benefit in poorer areas.