The Gauteng Premier sparked a storm of criticism on the election trail this week with his 'unrealistic' promises about universal healthcare (UHC), which despite what some politicians would like voters to believe, remains a long way off for South Africans, as is the case in several other countries.
As global experts outlined in The Lancet this week, UHC appears to have been put on the backburner, for various reasons, by numerous countries, particularly in those where it critically needs to be escalated.
Countries formally pledged to achieve UHC by 2030 through the UN Sustainable Development Goals (SDGs), and reinforced their commitments at two subsequent UN meetings in 2019 and 2023.
Yet plans to achieving this have not just stagnated, but deteriorated, writes the group, which has links to institutions like the WHO, Global Impact (Berlin), Organisation for Economic Co-Operation and Development (Paris), Thailand Ministry of Health, Imperial College London, and Waci Health in Nairobi, among others.
Of 194 WHO member states, 108 countries have had worsening or no substantive change in health service coverage since the launch of the SDGs in 2015.
This backsliding can be reversed and momentum reinvigorated for UHC by tackling several barriers to advancing UHC.
In 2023, attempts were made to address the first obstacle: political commitment, which frequently ends up as empty promises.
Despite a new multi-stakeholder Action Agenda from the UHC Movement aimed to progressively advance UHC through eight action areas and actionable milestones, many countries are still struggling to move beyond political rhetoric.
In South Africa, this has become an oft-used tool by politicians, especially during the pre-election phase when unrealistic proposals for UHC via the NHI are made in an attempt to woo voters.
Common in SA
A barrage of criticism was recently unleashed against Gauteng Premier Panyaza Lesufi after he made extravagant promises about NHI while on the campaign trail.
In a video clip, Lesufi was seen promising residents in disadvantaged communities that “anyone who votes for the ANC will be able to walk into any private healthcare facility, be it a clinic or a hospital, for medical assistance… and the government will pay”.
Lesufi then promised the demise of private medical aid schemes and escape from the poor state of public healthcare, saying: “Gone are the days when if you don’t have medical aid, you must die…or if you don’t have medical aid, you must be mistreated in our hospitals.”
Experts said this promise was clearly not feasible, not only because the Bill is still unsigned but because it’s far from being ready for implementation, reports News24.
A week ago, Dr Rajesh Patel from the Board of Health Funders (BHF) cautioned the national Department of Health to get its house in order first before even considering rolling out the Bill into practice.
He said implementation in its current form was a disaster waiting to happen, not only because there were no funding plans, but also because the government first needed to fix its shockingly maintained public hospitals.
Financial investment
The Lancet experts said this real lack of political commitment often reflects how UHC is incorrectly perceived by governments as the responsibility of the health sector alone, when instead, it actually requires multi-sectoral collaboration and whole-of-government commitment, with adequate financial investment, social participation and civil society engagement.
Moreover, policy action is also hampered by inadequate implementation capacity and health system challenges, like insufficient numbers of health workers, poor supply chains, and a shortage of pharmaceuticals and diagnostic technologies – all of which hamper public healthcare service delivery in South Africa.
In many countries these issues are not easy to resolve. Since UHC is often framed through ambiguous commitments that can ultimately leave political leaders unaccountable, there is a need for a new clear roadmap for UHC and guidance on how to implement UHC reforms.
Another barrier is that financing for UHC remains inadequate and unsustainable and does not address everyone’s needs.
Reform crucial
In South Africa, a vague but unrealistic financing structure for NHI has been slammed by numerous objectors, including opposition parties, big business and medical professional organisations.
Khulekani Mathe, writing in the Sunday Times, said amending the NHI Bill to allow for private sector participation in funding and provision of care would not only strengthen the system but also unlock new and more immediate opportunities for innovation and job creation.
While there were undoubtedly areas needing reform in both the public and private healthcare sectors, he wrote, it was important to recognise there are also areas of world-class excellence, notably the many outstanding healthcare professionals and hospitals operating in both domains, and it was vital that reform secured and improved rather than damaged these areas of excellence.
The South African Health Professionals Collaboration, a group of about 25 000 public and private healthcare doctors, dentists, specialists and allied healthcare workers, has also raised concerns about the Bill, while the Public Servants Association cautioned that significant issues needed to be addressed to ensure the NHI’s success, and to mitigate negative consequences.
Mathe said it was particularly concerning that the transition to the NHI would result in public servants losing out on the medical aid subsidy they now receive through the Government Employees Medical Scheme, which would increase their financial burden.
This would not only affect public sector employees, but every citizen with a medical aid subsidy as part of their employment benefit package, as well as those benefiting from medical scheme tax credits that reduce their personal income tax burden.
He said all medical scheme members, whether in the public or private sectors, have invested their own after-tax income to secure theirs, and their families’ healthcare needs.
“Redistribution and cross-subsidies are important principles in our highly unequal society, but this needs to be carefully constructed to ensure long-term sustainable access to healthcare, which is both a social and economic imperative.”
In the current version of the NHI Bill, the government plans to divert money now being paid in medical scheme contributions in the private sector into the public sector.
“The fact is, though, that this money doesn’t belong to the state, but to private citizens. The only way for the government to divert this money is by imposing a heavy tax burden on its citizens.
“The financial risks to the country and taxpayers are substantial. The Department of Health has not yet defined the package of benefits that the NHI will offer, so the true costs are thus far unknown.”
The government will also need to raise an additional R200bn each year to supplement the current national health budget, from a combination of increases in VAT, payroll and personal income taxes.
To raise an extra R200bn per year, the government will need to increase VAT from 15% to 21%, or raise personal tax by 31%, or a payroll tax that is 10 times higher than the current UIF contribution, or a combination of these.
Raising income tax by a third is simply unaffordable for a declining tax base already under enormous financial strain, and raises significant economic risks for the country overall, with knock-on effects which do not seem to have been given due consideration to date, he wrote.
Even if the government were able to raise this money, it would mean that the package of services citizens can access through the NHI would still be extremely limited.
For instance, if the NHI package of benefits is only available in the NHI Fund once it is fully implemented, those now on medical aids will only have access to less than one-third of the benefits that they now access through their medical aids.
Fewer benefits
This will be the case even allowing for more efficient purchasing mechanisms. This is akin to asking someone who now pays R100 to receive 100% of the benefits to continue paying R100, but only receive 30% of the benefits.
This leaves medical scheme members with the challenge of having to find additional funding in their already-stretched household budgets to preserve access to existing benefits. Clearly, this is an unsustainable situation, which is also constitutionally unsound.
Restricting the participation of medical schemes in financing healthcare services would create uncertainty for the broader private healthcare and business sectors, he wrote.
Importantly, there is no other country in the world that places a legislative limitation on access to private healthcare cover to its citizens, not even the wealthy countries with a substantial tax base.
Work together
And yet, while the NHI appears blind to the sense in long-term collaboration with private medical schemes, partnership between the public and private sectors is acknowledged as being vital, with The Lancet group writing that donors, countries and partners need to strengthen and increase joint efforts to tackle debt servicing, waste and corruption in health spending, and implement commitments made on aid effectiveness.
These stakeholders need to work more effectively together to catalyse and increase domestic public financing for health and financial protection and better align all health financing flows.
Fragmentation of financing and lack of alignment behind national health systems and priorities continues to hamper effectiveness, they wrote, and financing must include a focus on financial protection and address key financing questions, like the need to ensure progressivity of revenue collection, the design of health benefit packages, and strategic purchasing of health services.
Funding decisions must be country-driven, and needs on issues like non-communicable diseases, primary healthcare, and health system strengthening, including the health and care workforce, must become priorities that all stakeholders (inter-governmental, non-governmental, and private sector) strive to help governments achieve.
Global health initiatives – pooled financing organisations and private funders – could have a stronger role in catalysing and aligning behind required long-term investments in these areas, accelerating national system-strengthening efforts, they suggested.
This investment is particularly important in low-income countries, where tax revenue collection alone may not be sufficient to pay for UHC and overseas development assistance remains an important source of funding.
Country-driven policy and decision-making must go beyond government action alone, and include meaningful, independent social participation in policy making, implementation, and funding decisions, the experts wrote.
How advocates communicate about UHC is another stumbling block.
The global health community typically fragments into factions advocating for different (albeit related) priorities, including specific diseases, UHC, primary healthcare, health security, and health systems, but this can make it difficult to harness political will and may confuse political leaders.
For UHC to resonate and prompt political action, accessible, clear explanations and framing of UHC are needed in policy dialogue.
Achieving a shared understanding of UHC that encompasses its three dimensions of service coverage, population coverage, and financial protection coverage, and elucidating how UHC is essential to expand access to quality health services without financial hardship, is crucial.
“We call on all stakeholders to hold political leaders accountable for tangible actions to advance their political commitments to UHC; to centre UHC in advocacy and action; to build coalitions for UHC beyond the health sector; to advocate for increased domestic financing for health and universal social protection; and to develop and align around a UHC roadmap that addresses key drivers and enablers of UHC and clearly identifies which organisations or entities have responsibility for which part of the work.
“Collective action can ensure that UHC does not remain a mere aspiration.”
Mathe is the CEO-designate of Business Unity South Africa
TimesLIVE article – Private sector must participate in NHI (Restricted access)
News24 article – WATCH: Lesufi slammed for his NHI electioneering ‘lies’ (Restricted access)
See more from MedicalBrief archives:
Income tax hike and payroll tax proposed for NHI funding
NHI tax ‘ask’ unaffordable, says organised business
NHI heading for ‘Eskom-level stuff-up’
Global health-financing mechanism key to UHC
Lessons for SA from Rwanda’s universal health insurance scheme
SA can afford health coverage for all — UK expert