By Magome Masike
Johannesburg - “Everybody can be great because everybody can serve.” – Martin Luther King, Jr. “Life’s most persistent and urgent question is: What are you doing for others?” – Martin Luther King, Jr. “Earn your success based on service to others, not at the expense of others.” – H. Jackson Brown Jr.
I came to know Dr Maelane as a health activist in the late 80s when some of us had just started medical practice. Those of you who are old enough will recall a march led by Dr Joe Jivhou, Dr Makaba and Dr Joe Maelane in the early nineties. Issues of medical aids dictating to black medical doctors how they should conduct medical practice, payments that were not honoured etc.
A calm person, with very good listening skills which explained why we have two ears and one mouth, we must listen twice as much as we speak.
What we enjoyed speaking about: HEALTH CARE
-Patient care - our last discussion on Thursday before his departure
-Comparative healthcare systems
Brazil, Russia, India, China, and South Africa (BRICS) not only represent 43% of the world's population, but also, as the former WHO Director-General Margaret Chan declared, “represent a block of countries with a fresh and invigorating approach to global health”, and as such challenge existing global health orthodoxy.
At the World Health Assembly in May 2012, the BRICS countries “stressed the importance of universal health coverage (UHC) as an essential instrument for the achievement of the right to health [and] welcomed the growing global support for UHC and sustainable development”. Because there is not yet a standard, internationally agreed quantitative framework measure progress towards UHC.
Defined as access to needed health services and financial risk protection, UHC is a shared health policy goal for all the BRICS countries and is increasingly regarded as an overarching goal for health in the post-2015 development agenda. Although there are notable differences within and across these countries in terms of wealth, health indicators, and systems, a simple framework can be used to assess health systems and reforms towards UHC (as defined in the 2010 World Health Report), and consider these efforts and remaining challenges.
In South Africa, because of apartheid’s legacy, considerable disparities in health status across race groups remain. For example, life expectancy in 2004 ranged from 64 years for white people to 49 years for black people. There are also inequalities across geographical areas. Despite a constitutional obligation to the right to access health services, the health system remains deeply divided, with the richest people covered by private insurance and everyone else reliant on poorly resourced public sector services. Low-income and middle-income formal sector workers also face financial protection challenges.
The health system falls far short in the provision of equitable access to needed, effective healthcare. The poorest groups have lower rates of health service use and derive fewer benefits from the use of health care, despite the burden of ill health is far greater on these groups. There are considerable barriers to access, particularly for the poorest people. There is an absolute shortage of health workers and an uneven distribution between sectors and geographical areas.
The government is committed to moving towards UHC over 15 years, with three 5-year phases. The first phase will create conditions for efficient and equitable provision of high-quality public services by addressing infrastructure deficiencies and ensuring routine availability of essential medicines and other quality improvement strategies.
Although the government is committed to pursuing UHC, these plans face opposition from some groups, although often not overtly. Private insurance schemes and providers are concerned that they will be adversely affected by the reforms. The National Treasury has financial feasibility concerns, particularly because of the current global economic crisis. Reform is focused on the creation of a solid primary health foundation, including preventive and promotive services.
Strong purchasing power and effective provider payment mechanisms are also crucial. Modelling of the resource requirements for UHC indicates that although total expenditure on healthcare would increase only slightly (at more than 8% of GDP), spending from public funds would need to increase from present rates of around 4% of GDP to more than 6%.
However, there are risks of pooling all funds in a single fund, particularly in the absence of robust governance and accountability mechanisms. These details have not yet been outlined in key policy documents.
Human resources are another serious challenge. Although reforms create an entitlement to a broad range of services, delivery will not be possible without additional staff. Several strategies are being explored, including task-shifting, increasing training capacity, and drawing on private sector resources.
Health is a fundamental human right, and universal health coverage (UHC) is critical for achieving that right. UHC represents the aspiration that good quality health services should be received by everyone, when and where needed, without incurring financial hardship. This ambition was clearly stated as a target in the United Nations Agenda 2030 for Sustainable Development and reaffirmed when world leaders endorsed the Political Declaration of the United Nations High-level Meeting on Universal Health Coverage in September 2019, the most comprehensive international health agreement in history.
Beyond health and well-being, UHC also contributes to social inclusion, gender equality, poverty eradication, economic growth and human dignity. This report reveals that pre-pandemic, gains in service coverage were substantial and driven by a massive scaling up of interventions to tackle communicable diseases, such as HIV, tuberculosis and malaria. And while impoverishing health spending has decreased in recent years, the number of people impoverished or further impoverished by out-of-pocket health spending has remained unacceptably high.
These trends are exacerbated by substantial and persistent inequalities between and within countries. The Covid-19 pandemic has subsequently led to significant disruptions in the delivery of essential health services. Rising poverty and shrinking incomes resulting from the global economic recession are likely to increase financial barriers to accessing care and financial hardship owing to out-of-pocket health spending for those seeking care, particularly among disadvantaged populations.
The pre-Covid challenges, combined with additional difficulties arising from the pandemic, bring even greater urgency to the quest for UHC. Strengthening health systems based on strong primary healthcare (PHC) is crucial to building back better and accelerating progress towards UHC and health security. Effective implementation of PHC-oriented health systems enables greater equity and resilience, with greater potential to deliver high-quality, safe, comprehensive, integrated, accessible, available and affordable healthcare to everyone, everywhere, but most especially the most vulnerable.
Substantial financial investments in PHC-oriented building blocks of health systems, particularly in the areas of greatest expenditure (health and care workforces, health infrastructure, medicines and other health products) should be supported, carefully planned and informed by health system performance data to address critical gaps, particularly in low-income and lower-middle income countries. There is also an urgent need to remove remaining barriers to enable access to healthcare for all.
Key barriers to UHC progress include poor infrastructure, with limited availability of basic amenities, weaknesses in the design of coverage policies to limit the harmful effects of out-of-pocket payments particularly for the poor and those with chronic health service needs, shortages and inefficient distribution of qualified health workers, prohibitively expensive good quality medicines and medical products, and lack of access to digital health and innovative technologies.
Maintaining progress towards UHC is likely to be challenging. UHC is first and foremost a political choice. It is also a moral imperative to guarantee the right to health for all. More than ever before, strong political commitment from world leaders and partner organisations is the essential ingredient for overcoming barriers.