The spread of Covid-19 has positioned health policy front and centre for countries across the world. Scrutiny has been placed on the healthcare models that are implemented and which are the most effective at saving lives.

In the US, a heavily privatised system has been criticised for the manner in which it excludes vulnerable citizens from being able to access quality healthcare, often burdening individuals with immense costs if they need to access emergency care.

In the UK, the state of the National Health Service (NHS) has come under immense strain with the volume of patients that have become sick with Covid-19 and have required care. There have been calls for increased funding from the government and the country has even seen mass donations from private citizens to safeguard this valuable service.

South Africa has a mixed system of private and public healthcare, with usage determined by income levels. More affluent South Africans generally adopt private healthcare coverage while lower-income households are more inclined to use services offered by the state.

The state of public hospitals faced intense scrutiny during the Covid-19 pandemic, with fears that they would be overwhelmed or face collapse due to a lack of resources. South Africa’s spending on health generally exceeds 8% of the country’s gross domestic product (GDP) and it is the largest funded item in the national Budget.

Covid-19 has seen a flurry of activity around the need to capacitate health services, channelling funds to medical technology, protective personal equipment and vaccine and treatment development, along with various other initiatives. All these are important processes, but the situation raises an intriguing counterpoint that is worth exploring.

The tendency when thinking about public health inclines towards strengthening treatment facilities and providing robust health coverage. However, as civilisation develops, how do we switch from being reactive in the approach to healthcare — with the government constantly responding to increasing demands and requirements — and move towards a proactive healthcare approach which seeks to ease strain on the system? How do we create a healthy populace?

The long-term strategic goal of the government’s National Development Plan (NDP) is to raise life expectancy to at least 70 years. Currently, it sits at about 63.5 years for men and 68.5 years for women, according to Stats SA. The biggest killers are non-communicable diseases (NCDs) such as cardiovascular diseases (heart attacks and strokes), cancer, chronic respiratory diseases and diabetes. The South Africa Medical Research Council (SAMRC) has identified four major common risk factors that drive NCDs, namely tobacco use, physical inactivity, harmful use of alcohol and an unhealthy diet.

Generally, the approach in most countries including South Africa is to introduce restrictions or penalties to discourage certain behaviours. For example, “sin taxes” are used to discourage the abuse of tobacco and alcohol. Use of tobacco is also restricted in both public and private spaces. In the past few years, a sugar tax has been introduced to restrict consumption of unhealthy foods.

However, at this point in South Africa, these regulations come across more as revenue-raising mechanisms then as actual health interventions.

Herein lays the policy opening, namely the opportunity to introduce health policy that actively promotes and incentivises healthier living. How then does the government create legislation that doesn’t focus on penalising unhealthy lifestyles, but rather seeks to incentivise healthy choices?

There are already some interesting models to engage with, one of which has been developed by medical aid provider Discovery. Through Discovery’s Vitality programme medical scheme members are encouraged to invest in healthy living and wellness. Members get rebates on gym membership, discounts on healthy foods and rewards for hitting fitness goals and undergoing prescribed health checks.

For a medical insurer to enhance their revenue they need to ensure their members are not frequently in and out of hospital or regularly visiting the doctor. The best way to do this is to encourage members to be healthy and then keep them there.

This model and thinking could be tremendously useful in terms of the public healthcare sector. The unhealthy lifestyle decisions made by individuals have long-lasting costs on the health sector, particularly as people age and choices they have made begin to catch up with them and manifest as various ailments or conditions.

An environment in which the majority of the general populace maintains a certain level of physical wellbeing puts less strain on the public health sector and allows a government to decrease costs of curing preventable conditions. A healthier populace can also work for longer, generating increased tax revenue into the future.

Statistics from the World Health Organisation indicate that more than 50% of South adults are overweight. According to Discovery, obesity incurs an additional healthcare cost of R4,400 a year for each person. That should be the starting point for the government. Obesity is a leading driver of many health conditions. To tackle it, the government should focus attention on two areas of intervention: nutrition and physical wellbeing. The next question is: What could such a model potentially look like?

Such scenarios are win-win for all parties involved, but for the government the long-term savings in maintaining a healthy population are immense. It would save billions in potential healthcare costs. For individuals, not only are there financial incentives to motivate lifestyle changes, but if the changes are made there are obvious personal and wellness benefits.

Starting with nutrition, there is a simple intervention that could help to introduce healthier eating habits for South Africans. South Africa’s value-added tax (VAT) system allows for 19 basic items to be taxed at a rate of zero percent. These include various foodstuffs, many of which are healthy, such as vegetables, fruits, eggs, brown bread, milk and a few others. However, it could easily be expanded to include more products containing whole grains and unflavored yoghurt. No meat products aside from tinned pilchards have a zero VAT rating.

While it may be controversial, the inclusion of a selection of particular lean cuts of fish or chicken could hold immense value in stimulating healthy eating practices.

In many cases, processed and unhealthy food is cheap, making it more attractive to consumers, particularly low-income households. The only way to counter this is to increase the range of cheaper options of healthy food items that can be purchased. Zero-rating VAT policy has always been about offering support to low-income households. However, there is no reason why it cannot be leveraged as a tool to support health policy as well.

When it comes to physical wellbeing, it can get a bit harder and would require really adventurous thinking. The challenge is: How can the government get you to exercise regularly?

The benefits for the state are clear: a healthier and fitter population is less costly to maintain from a healthcare perspective. According to research from the WHO published in 2016, it is estimated that obesity-associated costs in South Africa alone came to R53.9-billion. Economics teaches us that individuals will respond to incentives, the best of which are generally financial incentives. Once again, it is worth considering how both health and tax policy can be used to support each other.

There are various ways to easily measure a person’s physical wellbeing, with standards universally agreed upon. Body mass index (BMI) is one, but there are many other metrics that can form part of a holistic rubric to assess your health status.

Assume, for example, that, at the beginning of a tax year, South Africans from across the country have to go to their local clinic for a health assessment. What if, at the end of the year, you do the same assessment and the results indicate that, within your age, weight and gender bracket, you are considered to be healthy and are entitled to a limited tax rebate?

Consider another hypothetical situation: After the initial assessment you are informed you are overweight, but you commit yourself to losing weight and the government pays you R1,000 for every one kilogram you lose over the year. In many cases this isn’t even a concept any longer, various private healthcare providers deploy variations of these tactics to keep their members healthy and active.

Such scenarios are win-win for all parties involved, but for the government the long-term savings in maintaining a healthy population are immense. It would save billions in potential healthcare costs. For individuals, not only are there financial incentives to motivate lifestyle changes, but if the changes are made there are obvious personal and wellness benefits.

Covid-19 has scared many individuals who, perhaps, in one way or another, have faced their mortality and confronted lifestyle choices. Taking this further, there is a unique opportunity to start rethinking core goals behind health policy. DM