The world’s first United Nations declaration on universal health coverage (UHC) will not include any mention of sexual and reproductive health rights — and activists say US President Donald Trump’s administration is largely to blame. Meanwhile, South African experts say other controversies around the document — including who has a seat at the table — mirror fights about the country’s own UHC financing model, the National Health Insurance (NHI).

UN member states including South Africa are expected to sign the document, which has already been finalised, on Monday 23 September during the UN General Assembly in New York. The declaration is itself the product of months of behind-the-scenes battles between countries over the exact wording that heads of state will sign on to. Sexual and reproductive health was just one of several contestations that led to what some say is dangerously watered-down language both on what universal health coverage should mean and countries’ duties to displaced people at a time of unprecedented forced migration.

For health experts in South Africa, some of the other quarrels playing out on the global stage mirror fights at home about the NHI — including how UHC should be defined and whether industry interests are being prioritized over patients.

US removes key wording

In the run-up to Monday, previous versions of the 13-page declaration would have committed the world to providing family planning services, sexual health information and education as part of people’s sexual reproductive health rights, says Itai Rusike.

Rusike is the executive director of the Community Working Group on Health in Zimbabwe. He is also a member of the UN’s official civil society engagement mechanism.

But the veteran health activist says US opposition has removed all wording save that around states’ obligation to provide pregnant women with care before, during and after childbirth. The move by the Trump Administration is its latest effort to curb access to sexual and reproductive health services – particularly for women — in the US and globally.

In 2017, Trump reintroduced the country’s Mexico City Policy, also known as the global gag rule. The law allows the US government to cut funding to organisations if they perform or promote abortions abroad, regardless if this is done with or without US money.

Research by the non-profit Kaiser Family Foundation presented at the 2018 International AIDS Conference estimated that at least 700 foreign and US organisations working abroad have been affected by the clampdown in funding.

That number is likely to have grown since US Secretary of State Mike Pompeo introduced an expanded gag rule in March which, in theory, gags smaller organisations who may get any type of funding – US or not – from larger bodies that are already gagged. Early indications from health policy watchdogs are that this may be affecting grants from other large international donors such as the Global Fund to Fight Aids, TB and Malaria.

Putting the ‘universal’ in UHC

The final draft of the UN declaration also contains weak language on countries’ commitments to providing healthcare that is truly universal.

The document describes UHC as care that includes “access for all, without discrimination”. But that commitment is immediately weakened by couching such access within what the declaration says should be a “nationally determined” set of services, argues Sulakshana Nandi, co-chair of the global network the People’s Health Movement.

In countries where access to healthcare is already limited, governments may use the watered-down language to get away with claiming they provide UHC even if they only offer a restricted package of services, she says.

And just as the term “UHC” has been contested in the run-up to Monday’s New York meeting, so too has the phrase been hotly debated here in South Africa — and, perhaps, misused, says Percy Mahlati speaking of South Africa’s NHI. Mahlati is a member of the Progressive Health Forum comprised of dozens of health experts and anti-apartheid stalwarts.

He explains: “Over the past 10 years, NHI has become confused with UHC. They are not the same – NHI is just a funding mechanism. It’s not going to cure the bad behaviour in the public and private sector.”

While no one has any doubt that South Africa needs a major overhaul to address glaring inequalities in its health system, there is no guarantee that the NHI Bill as it is now will do anything to improve the quality of care in the country, Mahlati warns.

Although South Africa’s public healthcare system suffers from poor quality it includes — in theory — access to a wide range of services that are either free or highly subsidised depending on a patient’s income, which many other countries do not. Instead, nations such as Sierra Leone that have been traditionally more reliant on patients paying out-of-pocket for services have begun to inch towards UHC by first making a select package of services free.

Nandi says the declaration’s loose definition of UHC does nothing to force the hand of governments that already willingly exclude marginalised populations such as migrants, refugees and internally displaced people.

Globally, more people are on the move than ever before. One in 30 people in the world were living outside their home country in 2017, a report by the UN Department of Economic and Social Affairs found.

The UN High Commissioner for Refugees estimates that conflict and persecution displace nearly one person every second.

While Monday’s UN declaration will commit states to addressing the needs of these growing groups, it again leaves it up to countries’ discretion if and how much it will cover populations such as these. Ultimately, she warns, the weak wording could escalate human rights violations among the world’s displaced people.

“Such a large political declaration drives a lot of policies and interventions, it should go beyond the borders of countries”, Nandi argues.

What’s missing from the final resolution speaks the loudest, she says.

She called the declaration “uninspiring.”

Big dreams, big business

But Nandi and Rusike agree, there’s another glaring omission in what stands to be the world’s foremost document on UHC: Big Business.

While it briefly mentions a commitment to preventing diseases such as hypertension and diabetes and providing access to affordable medicines and healthcare, the document makes no mention of the role of industries such as tobacco, sugar and processed food in contributing to poor health. Or, for that matter, of the pharmaceutical and private insurance industries that are pushing up the costs of healthcare.

In South Africa, the national health department is still sorting through the thousands of comments it got on its new, harsher tobacco bill, says the head of the South African Non-Communicable Disease Alliance, Vicki Pinkney-Atkinson. What’s more, the government has withheld a 2013 alcohol bill from the public, violating its constitutional obligations, independent researcher Michelle du Toit wrote for Bhekisisa last year. Although few have set eyes on the document, the legislation was meant to address the link between alcohol advertising, alcohol abuse, and related issues such as gender-based violence.

And, a new patent policy that was supposed to help lower medicine prices is still collecting dust, says Sasha Stevenson, the head of health at public interest law organisation SECTION27.

Pinkney-Atkinson says: “Everything has been put on hold for the NHI.”

From New York to Pretoria: Who is charting the course to UHC?

In South Africa, consultations for the UN high-level declaration on UHC were coordinated by the South African National AIDS Council (Sanac).

Pinkney-Atkinson criticised these consultations as being narrow and flimsy. She added that those in the room were largely confined to HIV and TB organisations. Sanac’s organisation of civil society consultations around the NHI, at the behest of the president’s special adviser on social policy, Olive Shisana, have also been similarly criticised.

Sanac did not respond to requests for comment.

Consultations with the public and civil society around the NHI have also been insufficient, Stevenson says. Issues raised in the green and white papers, for example, showed up again in the bill, and the public has been given far too little time to participate in a meaningful way.

The department sent out a letter this week calling for nominations to the committee that will determine what benefits the NHI scheme will cover. Those interested had four days to apply. The notice was withdrawn.

Meanwhile, activists allege that patients are being ignored even in other consultation groups for the NHI.

When these concerns were raised ahead of last year’s Presidential Health Summit, a “user group” was set up by Shisana. The group is headed up by Lauren Pretorius, CEO at Campaigning for Cancer.

Nearly 40 civil society organisations are listed as having participated in this “user group,” which is supposed to represent patients’ interests, in the Presidential Health Compact produced at the summit. But at least six prominent organisations have told Bhekisisa they attended the summit but were not included in subsequent consultations as stated in the compact.

Those that were involved in patient group consultations included cancer patient lobby groups, such as Campaign for Cancer, that receive funding from pharmaceutical companies, according to websites and annual reports.

Pretorius admitted that she has accepted money from the pharmaceutical industry in her personal capacity as a consultant and as the head of Campaigning for Cancer. But this donor money comes with a contract that exempts the nonprofit from any obligation to serve companies agendas, she says.

“Campaigning for Cancer’s advocacy efforts are fiercely independent, patient-centred and effective,” Pretorius maintains.

According to the Presidential Health Compact, this patient group will form part of a “joint technical monitoring team” for the NHI and have a direct line to the NHI war room established by President Cyril Ramaphosa in February.

The Presidency did not respond to requests for comment.

“There are no representatives for the patients who will be using the NHI – the people of the country,” one activist said.

Pretorius said the user group had been created following the Presidential Health Summit, to which she says most patient groups were not invited. Those that had attended had undertaken to draw others into the NHI consultations but this, Pretorius says, never happened.

“As a result, the Presidency reached out to a group of patient groups to ensure we were included in the resulting multi-stakeholder dialogue,” she says. “This group, plus several other groups, formed what is now known as the ‘User Groups’ constituency.”

She added: “At a meeting held in December to discuss our involvement, there was a consensus reached that we would participate in the resulting dialogue and compact development but would reserve our approval of the summit report as we had not attended This is what we did.”

But it’s the patients in the far-flung areas of SA who need better quality healthcare the most, Mhlati argues.

He explains: “To think that we’re going to fix the quality of care by just changing the way it’s financed – we’re living in a fool’s paradise.” MC

This story was produced by the Bhekisisa Centre for HealthJournalism, bhekisisa.org as part of its series, “Compass: Charting a course to the NHI.” Subscribe to the newsletter http://bit.ly/BhekisisaSubscribe.