Johannesburg - While South Africa enjoys excellent private health care, its public health-care system is under constant scrutiny.
The World Population Review’s Best Healthcare in the World 2023 study ranks South Africa’s health-care system 87th in the world, behind the likes of Vietnam, Botswana, the Philippines, Sri Lanka and Mongolia.
Although South Africa’s public hospitals are often underfunded and understaffed, much of the system’s scrutiny comes as a result of the country not having a universal health-care system in place, and instead has two parallel systems that drive an ongoing divide between the country’s low- middle- and high-income socio-economic groups.
The public health-care system of South Africa is the backbone of its medical interventions and serves as many as 80% of its almost 60 million citizens. Alarmingly, 80% of doctors operate in the private system, leaving the public system critically short of professional resources and invariably constrained.
Universal health-care initiatives have proven effective in other countries in an attempt to bridge this divide and is something that the Department of Health aims to emulate in South Africa with its proposed National Health Insurance (NHI) initiative.
CEO of the Innovative Pharmaceutical Association South Africa (IPASA), Bada Pharasi, said one such example is Rwanda’s Universal Health Coverage (UHC) initiative, which has seen almost 90% of Rwanda’s population adequately covered for health-care-related issues.
“The successful implementation of the initiative received praise from the World Health Organization, which has noted that the country is performing exceptionally well in ensuring its population meets Goal 3 of the United Nations sustainable development goals that calls for good health and well-being,” said Pharasi.
This includes ensuring that the population has access to the medical services they require, irrespective of their circumstances and without the threat of impending financial ruin.
The country’s commitment to achieving this is evidenced by its 15.6% increase in health expenditure during the 2019/2020 financial year, which surpassed the 15% required by the former Organisation of African Unity’s Abuja Declaration – the entity now more commonly referred to as the AU.
To achieve this, the Rwandan government has, over the past few decades, built its strategy through several evidence-based and population-centric approaches. This includes increasing its health budget and the number of health-care facilities, as well as bolstering service delivery and broadening community-based health insurance schemes.
“Rwanda increased its number of health-care facilities from 1 036 in 2013 to 1 457 in 2020, which has greatly increased geographical accessibility and contributed to a reduction in the time spent to reach such a facility,” he added.
Furthermore, broadening community-based insurance schemes has provided access to health-care services to much of the population, and has reduced out-of-pocket costs – an expenditure which the majority of the poor and vulnerable simply cannot afford to incur.
At the same time, while Rwanda’s UHC initiative may appear on track and that the country has achieved close to universal health-care coverage which is regarded as a notable achievement, conversations suggest that there are glaring gaps that require immediate attention should the country want to meet its goal of 100% universal health-care coverage by 2030.
This includes implementing additional health-care financing reforms, identifying policy options to expand coverage in remote and rural regions, and evidence-based policy reforms to ensure a clear course for service delivery.
“As the backbone of Rwanda’s UHC target, its community-based health insurance programme comes with additional challenges. This includes a disproportionate risk equalisation in the social health-care insurance contributory system, unit costs exceeding some individuals’ income, cost escalations, and flaws in funding mobilisation and recovery,” Pharasi said.
Still, there is sufficient evidence to suggest that South Africa should not miss the opportunity to learn from Rwanda’s unique community-based health insurance programme and geographical expansion of accessibility.
Pharasi said to achieve South Africa’s National Health Insurance goal, the Department of Health will need to address the challenges presented by Rwanda’s UHC initiative, while also acknowledging and taking action on several problem areas in its own public healthcare system.
Research suggests that to prepare South African hospitals for the NHI initiative, finances, professional resources and staff numbers must be increased, infrastructure upgraded, access to medicines and equipment enhanced, and health-care workers given adequate training not only in their specific fields, but also on the intentions of the NHI.
Given that reports indicate that the additional R23.7 billion set aside by Finance Minister Enoch Godongwana for health expenditure over the medium term is insufficient for future health-care sector upgrades, there is crucial work to be done if South Africa wants its NHI initiative to be successful in the long term.