For universal healthcare and NHI to succeed, SA needs effective health promotion programmes and institutions

South Africa has a burgeoning epidemic of non-communicable diseases, contributing to about half of all deaths in the country. More than 20 million adults in SA are overweight or obese and this number is growing, with close to 70% of women either overweight or obese. At the same time, malnutrition and stunting are increasing with rising levels of food insecurity. The combined cost of undernutrition and obesity is estimated to be R62.33-billion per annum.

South Africans who drink consume an average of 28.9 litres of pure alcohol per year. Yet fewer than 40% of South Africans drink any alcohol. This means that those who do drink often drink in the most harmful way. We see the consequences of alcohol misuse in road crashes, violence against women and children, the negative impact on families and numerous illnesses including cancer.

While smoking prevalence decreased between the 1990s and early 2010s to 17.6%, the recent Global Adult Tobacco Survey showed the prevalence rising to 29.4% of adults, indicating that this is still a significant risk factor contributing to the burden of cardiovascular diseases and cancers.

Notwithstanding the decreasing number of new HIV infections in recent years,  more than 400 South Africans are infected every day with HIV, with young women bearing the brunt. From 2017 to 2021 the number of young teenagers (10-14 years old) giving birth increased by 49%. Since April, in the Eastern Cape alone, nearly 100 girls between the ages of 10 and 14 gave birth.

In our first article in this series, What would it take to turn National Health Insurance into universal healthcare?, we argued that successful implementation of universal healthcare (UHC) requires South Africa to prioritise primary healthcare, which is proven to deliver UHC cost-effectively.

We quoted the World Health Organization, which asserts that “primary healthcare that is impactful is one that includes primary care available to people closest to their communities embedded in a strengthened health system; empowerment of people and communities; and multisectoral action to address social determinants of health”, aka the root causes of disease.

Building on this, we now argue that if national health insurance (NHI) is to have any chance of improving health outcomes (whatever it looks like after the litigation and disputes about the current Act have been resolved), the root causes of diseases need to be more systematically and vigorously addressed across multiple levels and sectors.

This must start immediately.

That means prioritising multisectoral action to deal with preventable causes of disease and the empowerment of people and communities to address them. Unless we do this we will forever be on the back foot mopping up illnesses caused by factors outside of the health system while the tap of disease remains fully open; we will never be able to afford the human resource and health system capacity to treat all the resulting disease; nor will we have a healthy population.

Actions to improve health

The good news is that many steps can be taken almost immediately that will improve health and save lives and money.

For example, we could implement the World Health Organization global action plan to control alcohol, which our minister of health has already signed. To comply we would have to implement the Liquor Amendment Bill of 2016 which has never been passed and the Control of Marketing of Alcoholic Beverages Bill, proposed in 2012, which never saw the light of day. Why?

The alcohol industry is big and influential. Research has shown that it has been active in either blocking, delaying or shaping alcohol-related policy, preventing the implementation of both these Bills. In 2017, global alcohol sales exceeded $1.5-trillion in an industry dominated by a few companies with high profits.

Industry self-regulation entities such as Aware.org and corporate social responsibility investments such as the SAB Foundation fund sports, entertainment and many social projects that help maintain a favourable policy environment and public appeal for alcohol. This is while public health regulations lag behind industry innovations to increase access to alcohol, eg, the maximum size of beer bottles increasing from 750ml to one litre.

Sugar-sweetened beverages are a major cause of obesity. In 2018, South Africa introduced a tax on them called the Health Promotion Levy (HPL) in an attempt to decrease obesity, but the levy was introduced at a level lower than was thought to be impactful. Nonetheless, there have already been some health gains, especially among poorer populations.

However, the levy has not been increased with inflation nor ring-fenced for health promotion.

So why was the HPL not implemented at its optimal level? The answer lies again in vested interests, this time of the sugar and sugary beverage industries. Industry interference in this policy has been demonstrated in research by Petronell Kruger and others. They showed how the industry shifted the discussion from health to saying that the HPL would cause massive job losses. Yet they have been unable to provide any evidence for this.

Clean water and sanitation are critical for child health. Before 1994 a third of all SA households did not have access to piped water on their stands. Today, 30 years after the advent of democracy in SA, 17% of households are still without water and 12.5% of households have pit latrines with no ventilation. Even though we have made significant progress, this is not enough in an upper-middle-income country. Perhaps we have forgotten the children who died in pit latrines, including Unecebo Mboteni, Langalam Viki and Michael Komape.

Major obstacles

Are the major obstacles to providing critical services and health-promoting policies a lack of political will, failure to prioritise resources for basic service delivery (while acknowledging many competing priorities) or lack of implementation or technical capability? Or all of the above and more?

Perhaps it is related again to commercial and criminal interests. For example, the deputy minister of water and sanitation said this month that the “construction mafia” was destabilising water and sanitation projects worth billions of rands.

What about HIV? In 2022, the government distributed 45% fewer condoms than it did in 2018, even though we still have more than 150,000 new HIV infections per annum. Are the government and our people becoming complacent and believing that the worst of the HIV epidemic is over? The HIV prevention and treatment programme costs the country R30-billion a year. While new advances in HIV prevention such as a vaccine would be welcomed, we need to continue to do the basics to protect our young people.

Unless there is a formal and concerted attempt to promote health by dealing with the social and economic determinants of disease, there will never be enough money to provide universal access to healthcare services. Notwithstanding the minimal references to health promotion and disease prevention in the NHI Act, NHI will struggle to have an impact on health outcomes. So what actions need to be instituted alongside the NHI?

Below are steps we believe need to be taken urgently.

Establish a National Health Commission 

In July 2017 the Government Gazette set out some of the “institutions, bodies and commissions that must be established as part of NHI”. This included a National Health Commission (NHC), whose primary objectives and purpose are “to ensure optimal health and development outcomes for South Africa through the implementation of a health in all policies and all-inclusive approach to the prevention and control of non-communicable diseases”.

This places health promotion as an integral part of the NHI. Its terms of reference are worth quoting in full. They are to:

1. Systematically address the social determinants of non-communicable diseases across government sectors;


2. Comprehensively address the social determinants of non-communicable diseases between government and all relevant sectors of civil society, including non-government organisations, academia, representatives of labour and the private sector;


3. All sectors within government and civil society to jointly identify health-related development objectives and work collaboratively to achieve these objectives; and


4. All sectors that contribute to health and development outcomes of non-communicable diseases to be aware of their responsibilities and implement relevant policies and interventions as directed by the National Health Commission;

The NHC is envisaged as an intersectoral body (similar to the SA National AIDS Council or the Presidential Climate Commission) that recognises the importance of a “health in all policies” approach. The NHC has the potential to address health promotion, with its emphasis on a “whole-of-government” approach and close collaboration with academia and civil society.

However, since 2017 nothing has been done to establish the NHC. While the other structures mentioned in the Government Gazette have been included in the NHI Act, the NHC has disappeared. Does this signal a de-prioritisation of health promotion? We hope not!

Prioritise health promotion financing

Allocating a properly costed budget to execute health promotion strategies would be a major step forward to improving the health of South African people. But we must be clear: health promotion is not health education or changing the lifestyle of individuals only. These are small aspects of health  promotion. Ensuring that health is considered in all policy areas and programmes and dealing with the commercial interests, structural and societal factors that drive illness and injury, as well as ensuring a healthy environment, are critical to health promotion.

Provide research evidence for most cost-effective health promotion actions

Partnerships with universities and research institutions must be strengthened and funded to distill the best available evidence on an ongoing basis to inform the most cost-effective, health promotion policy choices across sectors so that we achieve the best impact with limited resources.

Monitor the social and economic determinants of health

Linked to this there is a need for ongoing monitoring of the social and commercial determinants of health. The health sector generally, and skilled public health professionals in particular, can play an important role in providing and analysing the data that track the progress and impact of policy choices and interventions around health promotion.

For example, during Covid-19, the Western Cape Department of Health correlated data on trauma patients visiting their emergency centres and juxtaposed this with the restricted hours to sell alcohol during lockdown. The effect was like a switch — when alcohol access was restricted, trauma cases went down; when alcohol access restrictions were lifted then trauma cases went up.

Source: Western Cape Department of Health & Wellness (Hectis System)

There is a need to develop more structured and systematic ways of gathering and sharing data with the public and policymakers about factors that promote health across sectors. The NHI Act commits the NHI Fund to undertake research, monitoring and evaluation to assess the impact of the fund on health outcomes. We suggest that this needs to be augmented with monitoring and research on social and structural determinants.

Involve communities and deepen social accountability 

A further area that needs immediate action is igniting the agency of communities to promote their own health as part of a broader social mobilisation and social accountability strategy. This can be made possible through health literacy, supported self-management and active public participation in decision-making that acknowledges assets brought by community members. This will deepen public agency, trust and social accountability.

Strengthen health education within the health services 

Every patient interaction with a health worker is an opportunity for health education. The view of health professionals is respected and trusted. Over and above health facilities, settings such as schools, workplaces and community health worker visits to households are important sites for reinforcing education and prevention.

Build upon and scale up existing models of intersectoral collaboration 

There are existing models that reveal the potential of intersectoral approaches which could be improved and used for health promotion. These include Operation Sukuma Sakhe in KwaZulu-Natal, the Whole of Society Approach in Western Cape and the more recently piloted District Development Model by the Department of Planning, Monitoring and Evaluation in the Presidency. There were also lessons to be learned about collaboration across sectors and levels of government during the Covid-19 pandemic and other disasters.

These highlighted that because people’s lives are integrated there is a need for an integrated approach to service delivery and health promotion and a need for distributed leadership and innovation across sectors and levels of government.

In conclusion, South Africa has the opportunity to start turning around its high rates of disease but this won’t happen by itself, and it won’t happen just by passing an NHI Act. It is our view that there is significant potential for carefully planned, evidence-based health promotion and intersectoral policies and interventions to have an impact on population health. All sectors of society have a role and a responsibility.

In particular, we believe the establishment of the NHC as a mechanism to support the implementation of health promotion is a national priority. Universal health coverage and NHI are worthy objectives but South Africa needs to prioritise health promotion and disease prevention in tangible and practical ways that reduce the demand for curative care and improve the health and wellbeing of the population. DM   

This is the second of a series of articles that suggest practical programmes and approaches that we believe could be the basis for a  reinvigorated programme for health reform focusing on what can be done now if there is will in the health sector and beyond to reprioritise public health. 

The authors write in their personal capacity. Sue Goldstein is a public health medicine specialist, managing Director at the SAMRC Centre for Health Economics and Decision Science-Priceless SA and a professor at the Wits School of Public Health. Krish Vallabhjee is a public health medicine specialist, an adjunct associate professor at the Health Systems and Policy Division, School of Public Health, University of the Cape Town and technical adviser to Clinton Health Access Initiative. Tracey Naledi is a public health medicine specialist, an associate professor of public health medicine, deputy dean: Social Accountability and Health Systems, Faculty of Health Sciences, UCT and chairperson of Tekano, Atlantic Fellows for Health Equity in South Africa. Atiya Mosam is a public health medicine specialist and an independent consultant and founder of Mayibuye Health which specialises in health systems strengthening, PHC and health financing. Mark Heywood is an adjunct professor at the Nelson Mandela School of Public Governance at UCT and an independent health and human rights activist.