South Africa’s history of renal transplantation spans 50 years. Today, renal transplantation in South Africa is hampered by poor donation rates, lack of governmental commitment to provide Renal Replacement Therapy (RRT), and functional inequalities in a 2-tiered, economically disparate health system. A floundering public health sector—serving approximately 75% of South African residents—struggles to meet basic population healthcare needs and appears to have regressed in its provision of RRT. In contrast, the private health sector has expanded considerably to achieve dialysis rates in-line with other middle-income countries. Consequences include very low renal transplant rates with severe limitations to access renal replacement treatment. South Africa has only 1 transplant program per 19 dialysis facilities. Six transplant programs (40%) are based in the state sector and are in the private sector. These numbers reflect the extensive discrepancies in actual renal transplant numbers per sector In the private sector, it appears that patients are about 9 times more likely to receive a renal transplant with a much smaller number of patients accessing a much larger opportunity of care. However, given that over two-thirds of South Africa seeks care in the state sector, one would expect state sector transplant numbers to be proportional to the population served in that sector.