I was truly humbled to serve on the Commission of Inquiry on National Health Insurance, appointed by then health minister, Dr Nkosazana Dlamini Zuma, in January 1995 and required to report in April that year. It was chaired by Dr Jonathan Broomberg and Dr Olive Shisana and consisted of technical experts appointed from the departments of Health and Finance and from private-sector organisations, as well as four international consultants with the following policy framework: universal and non-discriminatory access to quality primary healthcare for all South Africans, regardless of race, gender, income and place of residence; affordability and sustainability of the system; efficiency and cost control and consistency with the objectives of the Reconstruction and Development Programme.
The principles that informed the commission’s recommendations included that permanent residents should be guaranteed access, on equal terms, to all services provided by the publicly funded primary healthcare (PHC) system. This implies that the financial, geographical and other barriers to access PHC services and the quality of services delivered, should be equivalent for all users of the system.
The PHC system should build on and strengthen the existing public sector PHC system; be congruent with and strengthen the emerging district-based healthcare system; be based on a comprehensive primary healthcare approach and use population-based planning and delivery mechanisms; be fully integrated and consistent with other levels of the healthcare system; optimise the public-private mix in healthcare provision and ensure the redistribution of resources between the current private and public sectors; and preserve the choice of individuals to use private providers and to insure themselves for doing so.
There are 30 basic human rights recognised around the world, declared by the then 58 members of the United Nations General Assembly (48 voted in favour, none against, eight abstained and two did not vote) through the Universal Declaration of Human Rights, in Paris, France, on 10 December 1948. Article 25 states that “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. Motherhood and childhood are entitled to special care and assistance. All children shall enjoy the same social protection.”
The definition of universal healthcare (UHC) is outlined in a 2019 resolution adopted by the General Assembly and signed by member nations. It says that “universal health coverage implies that all people have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative, rehabilitative and palliative essential health services, and essential, safe, affordable, effective and quality medicines and vaccines, while ensuring that the use of these services does not expose the users to financial hardship, with a special emphasis on the poor, vulnerable and marginalised segments of the population.”
The preamble of the UN Agenda 2030 talks about “a spirit of strengthened global solidarity, focused in particular on the needs of the poorest and most vulnerable and with the participation of all countries, all stakeholders and all people”. This highlights the ambition of the Sustainable Development Goals (SDGs) to be used by everyone – from governments to civil society and the private sector – as guidelines to define global priorities and aspirations for 2030. The Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP), established in 2019, brings together 13 multilateral health, development and humanitarian agencies. Its goal is to help countries accelerate progress on the health-related SDGs targets, through a set of commitments, to strengthen collaboration across the agencies to take joint action and provide more coordinated and aligned support to country-owned and led national plans and strategies.
The SDG3 GAP is a platform for improving collaboration among the biggest players in global health, with specific but complementary mandates. Under the SDG3 GAP, agencies commit to aligning their ways of working to provide more streamlined support to countries and reduce inefficiencies. Although referred to as a “global” plan, the added value of the SDG3 GAP lies in coordinated support, action and progress in countries.
The International Labour Organization has a Strategy on Social Health Protection, recognising that the affordability of healthcare is a key issue in most countries. In high-income countries, increasing costs, financial constraints of public budgets and economic considerations regarding international competitiveness have all made social health protection reform a political priority. In many high-, middle- and low-income countries, providing affordable healthcare is high on the development agenda, given the large number of people lacking sufficient financial means to access health services.
Social health protection is increasingly seen as contributing to building human capital that yields economic profits through gains in productivity and higher macroeconomic growth.
Worldwide, millions are pushed into poverty every year by the need to pay for healthcare. The denial of access to medically necessary healthcare has significant social and economic repercussions. Aside from effects on health and poverty, the close links between health, the labour market and income generation affect economic growth and development. This may be attributed to the fact that healthier workers have a higher productivity and labour supply increases if morbidity and mortality rates are lower. Generally, social protection builds human capital that yields economic profits through gains in productivity and higher macroeconomic growth.
Universal social health protection ensures that all people in need have effective access to at least adequate care and is thus a key mechanism for achieving these objectives. It is designed to ease the burden caused by ill health, including death, disability and loss of income. Social health protection coverage also reduces the indirect costs of disease and disability, such as lost years of income due to short and long-term disability, care of family members, lower productivity, and the impaired education and social development of children due to sickness. It hence plays a significant role in poverty alleviation.
For many years it was commonly thought that introducing and extending social health protection in developing countries was premature because they were not economically mature enough to shoulder the financial burden associated with social security. It was argued that attention should first be focused on macroeconomic growth and that the redistribution through social transfers in cash or in kind should be postponed until the economy had reached a relatively high level of prosperity. That view associated social health protection only with consumption costs. At present, social health protection is increasingly seen as contributing to building human capital that yields economic profits through gains in productivity and higher macroeconomic growth.
If healthcare were the only or most important determinant of population health, then an opportunity-based account of justice and health would be right to focus solely on a right to healthcare. Many societies, and nearly all wealthy, developed countries, provide universal access to a broad range of public health and personal medical services. The primary social obligation is to assure everyone access to a tier of services that effectively promotes normal functioning and thus protects equality of opportunity. Universal healthcare is firmly based on the 1948 World Health Organization constitution, which declares health a fundamental human right and commits to ensuring the highest attainable level of health for all. As a foundation for universal healthcare, it is critical to reorientate health systems towards primary healthcare.
In countries with fragile health systems, the focus is on technical assistance to build national institutions and service delivery to fill critical gaps in emergencies. In more robust health system settings, it is about driving public health impact towards health coverage for all through policy dialogue for the systems of the future and strategic support to improve performance.
Access to healthcare is a particular concern given the centrality of poor access in perpetuating poverty and inequality.
Universal access to health and universal healthcare imply that all people and communities have access, without any kind of discrimination, to comprehensive, appropriate and timely, quality health services determined at the national level according to needs, as well as access to safe, effective and affordable quality medicines, while ensuring the use of such services does not expose users to financial difficulties, especially vulnerable groups.
The three dimensions of universal healthcare are population coverage, package of services provided and level of financial protection. Universal access to health and universal healthcare require determining and implementing policies and actions with a multisectoral approach to address the social determinants of health and promote a society-wide commitment to fostering health and well-being. The right to health is the core value of universal healthcare, to be promoted and protected without distinction of age, ethnic group, race, sex, gender, sexual orientation, language, religion, political or other opinions, national or social origin, economic position, birth, or any other status.
The right to have access to healthcare services is a basic human right guaranteed by section 27 of the Constitution, which provides “that everyone has the right to have access to healthcare services, including reproductive healthcare services, and no one may be refused emergency medical treatment”. The Freedom Charter’s principle nine of 10 – “There shall be houses, security and comfort” – is clear that “a preventive health scheme shall be run by the state; Free medical care and hospitalisation shall be provided for all, with special care for mothers and young children.”
Access to healthcare is a particular concern given the centrality of poor access in perpetuating poverty and inequality. South Africa’s apartheid history leaves large racial disparities in access despite post-apartheid health policy to increase the number of health facilities, especially in remote rural areas. According to the 2020 Global Healthcare Index, South Africa’s healthcare system ranks 49th out of 89 countries and out of a population of more than 62 million, only 17.4% are covered by a South African medical scheme. This means only 10.79 million have access to private medical care while more than 51.2 million don’t. Healthcare accessibility remains poor in rural areas and there are problems retaining physicians in the public system. Furthermore, only an estimated 27% of patients who need mental healthcare receive it.
The South African health system faces a range of systemic and structural challenges, including widespread inefficiencies, staff shortages, variability in skill sets between rural and urban areas and suboptimal care levels and patient management. Limited availability of healthcare resources is another barrier that may reduce access to health services and increase the risk of poor health outcomes. For example, physician shortages may mean longer waiting times for patients and delayed care. There are three major challenges facing South Africa’s healthcare system. First, the biggest problem is that the health needs of its people exceed capacity. Second, the vast majority of people don’t know their health status, which delays access to care. Third, the way the system is funded perpetuates inequality.
A set of six quality priorities for fast-tracking improvement have been identified: safety and security; long waiting times; drug availability; nursing attitude; infection prevention and control; and values of staff. Four overarching recommendations are made to ensure high-quality universal healthcare in South Africa: enhance governance and leadership for quality and equity; revolutionise quality of care; invest in and transform human resources in support of a high-quality health system; and measure, monitor and evaluate to ensure high-quality universal healthcare. It is anticipated that the NHI Fund will get a large amount from general taxes. Therefore, every person in South Africa will contribute to the fund because we will all pay some kind of tax. People with low income will not make any direct payment to the fund. DM
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