In the mid-1990’s the Division had an active heart transplant program performing almost 40 heart transplants a year in 1993 and 1994 (with very limited staff and other resources) but, by then, the Private Sector had also become involved in heart transplantation and Private Heart Transplant Units were set up, not only in Johannesburg (Johannesburg General Hospital), but also in Cape Town (Christiaan Barnard Memorial Hospital) as an off- spring of staff members of the Chris Barnard Division. More recently two additional private units were also set up in the KwaZulu Natal province. In essence, the well resourced and “luxurious” private sector gradually took over the predominant source of reliable heart transplant patients with good socio-economic support structures from the public sector and competed for the limited donor pool. This came on top of the administrations push to cut back on the number of heart transplants in the public sector. By the late 1990’s and early 2000’s the numbers of transplants performed in our Unit had fallen to less than 10 a year despite our best efforts to keep heart transplantation alive in our Department. Of some re-assurance is that with recent changes in government attitude towards cardiac diseases (belatedly accepting the WHO predictions of 2000) our transplants have started to pick up again and 2014 promises to return to 2000 levels. However, the current crisis stems from the natural shift of typical pre-2000 patients towards the private sector. Given the selection criteria of transplantation, the majority of pre-2000 heart transplant patients at Groote Schuur Hospital were middle-class patients on medical aid who presented to the single unit in the country performing transplants. As the hospital for the indigent majority of the population, there is a huge pool of patients depending on public hospitals who would need transplantation. Given first world criteria hitherto applied, such as formal dwelling, these patients were excluded. The challenge forward will be to find structures and systems of support which will make heart transplantation accessible to the high number of potential recipients in the country who are currently excluded from the private sector while also not qualifying as ideal transplant candidates in the public sector.