The recently launched World Bank and World Health Organisation (WHO) report on progress towards universal health coverage (UHC) suggests South Africa is on its way towards achieving universal health coverage, with its National Health Insurance scheme. The country received a score of 67 out of a possible 100. Countries in Scandinavia, the UK, and surprisingly the US received scores of greater than 80. To understand what these scores mean, one has to review the inputs used to generate the scores.
The authors used the following nine variables to compute UHC scores for each country: sanitation (at least basic); hypertension control; tobacco control; insecticide treated nets (which we don’t provide, defaulting to indoor-residual spraying); family planning; antenatal care (four-plus visits); immunisation coverage; HIV treatment and TB treatment. Readers may be surprised that
Tnone of these variables reflect on either financing available and affordability or availability of health workers – which are often raised as obstacles to the implementation of UHC.
While acknowledging that finding ways to score countries and that the attempt by the World Bank and WHO is a brave first attempt, the variables used and the quality of the data will be highly contested by many countries. As Japan’s experience illustrates, investing in human capital through the provision of education and health services is a good buy – better than investing in infrastructure.
Two recent papers in the Lancet by that country’s Prime Minister Shinzo Abe and Deputy Prime Minister and Minister of Finance Taro Aso shows its success as an industrialised country with almost no unemployment after World War II was linked to a decision to invest in human capital. Aso noted that countries should embark on UHC early in their development trajectory, and that it contributed to social stability and economic growth.
Interestingly, the Chinese Communist Party resolved at its 19th national party congress to lift 43 million people out of poverty by 2020. One of the interventions is to provide professional training to ensure that at least one person in every household is employed as they recognise that after training, people are more likely to find employment.
At the UHC Forum in Tokyo on December 14-15, World Bank president Jim Yong Kim surprised many when he confessed that for many years the bank got it wrong when it promoted heavy investment by countries in infrastructure through loans and grants. He noted that what countries should invest in is its people, human capital. He acknowledged that Japan, followed by the Asian Tigers (South Korea and Taiwan) all invested heavily in education and health to develop the potential of their citizens and that the World Bank now promotes UHC, because it promotes development and is a contributor to economic growth. In fact, Senegal President Macky Sall, who spoke at the meeting, noted that UHC was also a pre-requisite for peace and security.
Why are these leaders focusing on what might be termed “social services” and what is the justification for this? One is moral – or based on a human rights argument – that it is immoral in the 21st century that 100 million people are driven into poverty because of outof-pocket health care payments. As WHO director-general Dr Tedros Adhanom Ghebreyesus aptly reminds, this translates to three people every second being impoverished.
In South Africa, estimates are that the poorest receive less than 15% of health benefits but need more than 30% of services, while the richest 20% use almost 40% of services against a need of 10%. Simply put, the rich benefit far more from health services provided than the poor who need these services more. This level of inequity cannot contribute to the development of our country.
The other reason for this focus appears to be a realisation that development that leaves people, especially the most vulnerable, is not sustainable and does not provide the conditions for peace and stability.
It is interesting that even countries that have already reached UHC support the imperative for all countries to make need for health services as the only criteria for access to services, rather than an individual’s ability to pay for services. These countries, however, also face the problem of affordability. Their challenge, like countries still on the path to universal coverage, is to ensure that they can afford to provide these services. This has led countries to go back to the 1978 Alma Ata Declaration. What this means was clearly illustrated by Singapore Health Minister Gan Kim Yong at the UHC forum, with low birth rates and a rapidly ageing population the country is looking beyond 2030 (the date by which countries should achieve the sustainable development goals). Singapore is already changing its focus from health care to health, from quality to value and from hospital to community. These changes clearly reflect a return to the basics. Next year, we will commemorate the 40th anniversary of the Alma Ata Declaration, so a return to its principles may well be opportune.
The sentiments noted at the forum echo those embodied in the preamble to the Alma Alta declaration.
What was right in 1978 is still right today.
Let us not wait another 40 years to discover what we know today. Let’s implement the national health insurance system, South Africa’s version of universal health coverage.
SA is on track to achieve its aim of universal health coverage
*Yogan Pillay is the deputy director-general in the National Department of Health and attended the 2030 UHC Forum in Tokyo last month. He writes in his personal capacity.
