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
Read more in Daily Maverick: Let’s be pragmatic — the NHI has constructive and contentious aspects
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Driving a Rolls Royce certainly assures your survival in the case of an accident. Heavy, solid vehicles that surely will survive most collisions. So every citizen deserves one.
The question that has not been answered – and can not be answered – is who will pay for every citizen to be driven around in a Rolls Royce. Surely every citizen deserves a Rolls, so we should start the ordering process. Worry about the finances later…?
The last paragraph is very pertinent. What is being done currently to address these areas that should be prioritized to rapidly improve care and governance in the public system? Nothing, and government does not even acknowledged the extent of corruption and maladministrarion in public facilities. The government has failed for years to meaningfully address the frequently deplorable level of attitude and service delivery. It does not require a centralized NHI Fund to address these issues, it requires a transformation of attitude, which introducing NHI will do nothing to address in the public sector. This corruption, maladministration and the shocking attitudes towards service delivery need to be addressed as a first step to significantly improve access to and quality of care.
The very brief reference to paying for the NHI just says that everyone will pay more taxes, it does not acknowledge that the extent of taxes that will be expected to be paid, and that the actual impact of taxes on taxpayers has not been assessed, and that there is not even a funding model that has been developed.
All the tenets for universal access to healthcare already exist. That the private sector is better at providing quality healthcare is undeniable, and there’s the issue, isn’t it? The absolute and total incompetence, corruption and uncaring negligence of our ANC-led government has led to a public healthcare sector that cannot provide to the population it is meant to serve. Instead, it is a funnel for public funds to flow to comrades and cadres and their connected friends and families.
The NHI will solve none of this. Healthcare delivery to poor citizens and underserved communities are not dependent upon the NHI – it is dependent upon a functioning, capable state.
Well said. I seem to remember that the dreaded Apartheid still managed to provide good free health care for everyone (Baragwanath, King Edward, Pelonomi etc and clinics etc) that the incompetent and corrupt ANC have managed to trash.
Pelonomi is such a good example. And not just, that – look at the condition of all state hospitals in the Free State. Bloemfontein used to be a training ground for our medical professionals, with some of the best hospitals and education facilities in the country. Today, much of the city’s healthcare is a wasteland of neglect, falling apart due to corrosive corruption. What on earth is the NHI meant to fix about this state of affairs? All it will do is drag the last remaining functioning parts of the healthcare system to the ANC’s level – which is quickly degenerating even from an excessively low base.
So was Addington Hospital and Greys Hospital in Pietermaritzburg.
The common denominator between NHI and the current public healthcare system is that the same ANC cadres will be running it and we will have the same transformation policies where incompetent people are promoted.
Interesting, about a year ago the author wrote abiut south africa being a failed state, and how the ANC cannot be fixed, yet I see no mention of the other side of the coin to the NHI, the obvious corruption that will happen, the destruction of the Middle class through more taxes and the enormous effect this will have on the current medical care system in place. When I hear of these new governmental programs being out in place, all I see is another vehicle to divert moneybtonthe anc cronies, their families and buddies, and the attempt to drive South Africa towards the anc dream, a socialist/communist state where all power and money is concentrated at the top…
Dear Mr Mohale, it is arguable that healthcare is a human right however universal healthcare which denotes a type of healthcare system is not a human right.
You are trying to load the dice by mixing two issues.
Arguing healthcare is not a human right, is arguing against the many scholars etc who inform the UN, WHO. This is easier to say if you/those you love are unlikely to die coz of no access to care.
There are different arguments/points here. Intricately linked but shouldn’t be conflated:
1. Access to healthcare is a crucial determinant of e.g., jobs, which then determines if you/next generations can eventually pay for private insurance or taxes. This especially pivotal in a country or world where those without were/are predetermined & perpetuated by the legacy of inequality.
2. Health status is determined by many socioeconomic, political factors that the poor can’t escape without help.
3. The ANC messed up the functioning but unequal apartheid healthcare. Opposing parties have not really addressed this except criticise NHI/ANC. Criticism is fine and deserved. But
4. We need a way forward. Then suggest a workable alternative…other than arguing for unaffordable private or private-public partnerships that largely benefit the private sector. Pointing at UK to say NHI won’t work coz of expense often lacks understanding of what drives healthcare costs e.g big pharma
Yes, The NHI in its current form and at the present time is unworkable. The ANC is not trusted to work it or not squander it. If another party were to manage the fund, would it more palatable? Or are some against a system where anyone can have access to the same care except for the rich who may want extra/faster.
A workable alternative is a new government, and there-in lies our countries painful dilemma. A socialist mindset being driven by government is attractive for the poor and uneducated, however the “bread makers” are getting fewer and fewer and soon the ratio will be unsustainable. The ANC neither has the ability nor the desire to rescue South Africa from its own demise.
Yes, Big Pharma does its best to milk the NHS but changing demographics (i.e. people living longer) and advances in medical knowledge, plus explosion in what can be achieved by technology are far greater causes of the UK inability to keep up with the cost of the NHS. I speak from experience of being a surgeon in the UK throughout my professional career.
You had it in 1994 but since then your anc socialist mob have systematically destroyed every infrastructural and service structure related to health care and now you want to destroy the private sector and the right of people to choose who serves their health needs…You surely jest! PS just remember that the 6 % of the SA population who create the wealth and tax revenues to fund your socialist largess are scraping the bottom of their financial barrels so pray tell, how do you plan to fund this madness and moreover, have you not yet noticed the mass exodus of professional medical personnel from SA !?
If you take the argument to its natural absurd conclusion then nobody need work at all because food, shelter, education, healthcare etc are supposedly all rights to be provided by government. But since governments can only spend our own taxes, or go bankrupt, then we must acknowledge the important difference between a right that we must be allowed to pursue at (our own cost) without external interference and a right which government must provide free of charge. To ignore the difference is to be wilfully blind to reality.
A well argued article putting the case for access to high quality health care for all. I don’t think that many people would disagree. The problem lies in the final paragraph, in which the pre-requisites for a high quality health care system for all South Africans are presented. On all of these four overarching recommendations the ANC has failed miserably: 1. enhance governance and leadership for quality and equity – the ANC has admirably demonstrated that it is totally incapable of enhancing any governance; 2. revolutionise quality of care – the ANC has admirably demonstrated that it has no revolutionary ideas and cannot motivate anybody to perform quality work; 3. invest in and transform human resources in support of a high-quality health system – the ANC has screwed up NSFAS, its BEE policies have driven desperately needed skills into retirement or overseas; 4. measure, monitor and evaluate to ensure high-quality universal healthcare – again the ANC has admirably demonstrated that it has no clue about measuring performance, not of politicians, not of provincial or municipal management, not of any of the executives of SOEs. The concept of universal access to health care is a good one, but the ANC is a bad one that cannot be trusted because it has failed so dismally over 30 years.
Universal Healthcare is a fundamental human right… that the NHI will miserably fail in providing due to ANC mismanagement and corruption. It will follow the path of the Dodo, or every other SOE in SA, and drag the rest of the healthcare industry, if not the economy, down with it.
Education does not unmake a fool. Now for food, education, transport…
Well, thank you very much for your much needed enlightenment and input.
The NHI is a very important and very necessary health care system that will enable us people of Mzansi to have access to much needed health services.
We are all waiting and longing for its implementation!
So when did a right to basic healcare morph into comprehensive healthcare?
The poor is also contributing to their own status by having multiple children that they can’t look after. Furthermore, they keep on voting for the ANC who follows policies that does NOT grow the economy and keep them unemployed. They should bear the consequences of their choices, that is how life works. The few taxpayers can’t continually bail the poor out from their self-destructive choices!
It is also not correct to imply that an unemployed person receiving the R350 pm grant is contributing to tax that fund the NHI. If they just buy basic groceries, they are not paying VAT as it is zero-rated.
Everybody (sorry, all citizens) have access to health care in the country, the service in the public sector is just shitty. And it’s ridiculous to think the private sector will continue to provide better services if the government is paying them.
This entire debate is confused because no acknowledgement is given to the counterpoint of every alleged “right”. And that counterpoint is an “obligation”. For every right you assert, there is an obligation from someone else. Your right to healthcare means there is an obligation somewhere by someone to pay for / sustain that right. Pray tell, who the f is that “someone”?