Compass: Charting a course to the NHI
On Monday, world leaders will sign a UN declaration that could have committed the world to provide decent healthcare for all. But instead, activists say, some of the world’s biggest health issues sparkle in their absence. Find out what it means for South Africa’s National Health Insurance in the latest in our new series, Compass: Charting a course to the NHI.
The world’s first United Nations declaration on universal health coverage (UHC) will not include any mention of sexual and reproductive health rights — and activists say US President Donald Trump’s administration is largely to blame. Meanwhile, South African experts say other controversies around the document — including who has a seat at the table — mirror fights about the country’s own UHC financing model, the National Health Insurance (NHI).
UN member states including South Africa are expected to sign the 10 September version of the document, which activists believe is likely include wording that will be reflected in the final draft, on Monday during the UN General Assembly in New York. The declaration is itself the product of months of behind-the-scenes battles between countries over the exact wording that heads of state will sign onto. Sexual and reproductive health was just one of several contestations that ultimately led to what some say is dangerously watered-down language both on what universal health coverage should mean and countries’ duties to displaced people at a time of unprecedented forced migration.
For health experts in South Africa, some of the other quarrels playing out on the global stage mirror fights at home about the NHI — including how UHC should be defined and whether industry interests are being prioritized over patients.
US removes any mention of comprehensive sexual and reproductive health rights
In the run-up to Monday, previous versions of the 13-page declaration would have committed the world to providing family planning services, sexual health information and education as part of people’s sexual reproductive health rights, says Itai Rusike.
Rusike is the executive director of the Community Working Group on Health in Zimbabwe. He is also a member of the UN’s official civil society engagement mechanism.
But the veteran health activist says US opposition has removed all wording save that around states’ obligation to provide pregnant women with care before, during and after childbirth. While the final draft did retain a commitment to improving the sexual and reproductive health of populations, it did not include mention of sexual and reproductive health rights, wording activists believe does not do enough to protect people’s choice have an abortion.
The move by the Trump Administration is its latest effort to curb access to sexual and reproductive health services — particularly for women — in the US and globally.
In 2017, Trump reintroduced the country’s Mexico City Policy, also known as the global gag rule. The law allows the US government to cut funding to organisations if they perform or promote abortions abroad, regardless of whether this is done with or without US money.
Research by the non-profit, the Kaiser Family Foundation, presented at the 2018 International Aids Conference, estimated that at least 700 foreign and US organisations working abroad have been impacted by the clampdown in funding.
That number is likely to have grown since US Secretary of State Mike Pompeo introduced an expanded gag rule in March which, in theory, gags smaller organisations who may get any type of funding – US or not – from larger bodies who are already gagged. Early indications from health policy watchdogs are that this may be affecting grants from other large international donors such as the Global Fund to Fight Aids, TB and Malaria.
Putting the ‘universal’ in UHC
The final draft of the UN declaration also contains weak language on countries’ commitments to providing healthcare that is truly universal.
The document goes to pains to describe UHC as care that includes “access for all, without discrimination”. But that commitment is immediately weakened by couching such access within what the declaration says should be a “nationally determined” set of services, argues Sulakshana Nandi, co-chair of the global network the People’s Health Movement.
In countries where access to healthcare is already limited, governments may use the watered-down language to get away with claiming they provide UHC even if they only offer a restricted package of services, she says.
And just as the term “UHC” has been contested in the run-up to Monday’s New York meeting, so too has the phrase been hotly debated here at home with regards to the NHI — and perhaps misused, says Percy Mahlati. Mahlati is part of the Progressive Health Forum comprised of dozens of health experts and anti-apartheid stalwarts.
He explains: “Over the past 10 years, NHI has become confused with UHC. They are not the same — NHI is just a funding mechanism. It’s not going to cure the bad behaviour in the public and private sector.”
While South Africa needs a major overhaul to address glaring inequalities in its health system, there is no guarantee that the NHI Bill in its current form will do anything to improve the quality of care in the country, Mahlati warns.
Although South Africa’s public healthcare system suffers from poor quality, it includes — in theory — access to a wide range of services that are either free or highly subsidized, depending on a patient’s income. Many other countries don’t offer as many benefits. Instead, nations such as Sierra Leone that have been traditionally more reliant on patients paying out-of-pocket for services, have begun to inch towards UHC by first making a select package of services free.
According to Nandi, the declaration’s loose definition of UHC does nothing to force the hand of governments who already willingly exclude marginalised populations such as migrants, refugees and internally displaced people.
Globally, more people are on the move than ever before. One in 30 people in the world were living outside their home country in 2017, a report by the UN Department of Economic and Social Affairs found.
While Monday’s UN declaration will commit states to addressing the needs of these growing groups, it ultimately again leaves it up to countries’ discretion if and how much it will cover populations like these. Ultimately, she warns, the weak wording could escalate human rights violations among the world’s displaced people.
“Such a large political declaration drives a lot of policies and interventions, it should go beyond the borders of countries,” Nandi argues.
What’s missing from the final resolution speaks the loudest, she says.
Ultimately, she called the declaration “uninspiring”.
Big dreams, big business
But Nandi and Rusike agree, there’s another glaring omission in what stands to be the world’s foremost document on UHC: Big Business.
While it briefly mentions a commitment to preventing diseases such as hypertension and diabetes and providing access to affordable medicines and healthcare, the document makes no mention of the role of industries such as tobacco, sugar and processed food in contributing to poor health. Or, for that matter, of the pharmaceutical and private insurance industries that are pushing up the costs of healthcare.
In South Africa, the national health department is still sorting through the thousands of comments it got on its new, harsher tobacco Bill, says the head of the South African Non-Communicable Disease Alliance Vicki Pinkney-Atkinson. What’s more, the government has withheld a 2013 alcohol Bill from the public, violating its constitutional obligations, independent researcher Michelle du Toit wrote in an op-ed for Bhekisisa last year. Although few have set eyes on the document, the legislation was meant to address the link between alcohol advertising, alcohol abuse, and related issues such as gender-based violence.
And, a new patent policy that was supposed to help lower medicine prices is still collecting dust, explains Sasha Stevenson, the head of health at public interest law organisation Section27.
Pinkney-Atkinson explains: “Everything has been put on hold for the NHI.”
From New York to Pretoria: Who is charting the course to UHC?
In South Africa, consultations for the UN high-level declaration on UHC were coordinated by the South African National Aids Council (Sanac).
Pinkney-Atkinson criticised these consultations as being narrow and flimsy. She added that those in the room were largely confined to HIV and TB organisations. Sanac’s organisation of civil society consultations around the NHI, at the behest of the president’s special advisor on social policy Olive Shisana, have also been similarly criticised.
Sanac did not respond to requests for comment.
Consultations with the public and civil society around the NHI have also been insufficient, Stevenson says. Issues raised in the green and white papers, for example, showed up again in the Bill, and the public has been given far too little time to participate in a meaningful way.
The department sent out a letter this week calling for nominations for the committee that will determine what benefits the NHI scheme will cover. Those interested had four days to apply. The notice was withdrawn.
Meanwhile, activists allege that patients are being ignored even in other consultation groups for the NHI.
When these concerns were raised ahead of last year’s Presidential Health Summit, a “user group” was set up by Shisana. The group is headed up by Lauren Pretorius, the chief executive officer at Campaigning for Cancer.
Nearly 40 civil society organisations are listed as having participated in this “user group”, which is supposed to represent patients’ interests, in the Presidential Health Compact produced at the summit. But at least six prominent organisations have told Bhekisisa they attended the summit but were not included in subsequent consultations as stated in the compact.
Those that were involved in patient group consultations included cancer patient lobby groups, such as Campaigning for Cancer, that receive funding from pharmaceutical companies, according to websites and annual reports.
Pretorius admits that she has accepted money from the pharmaceutical industry in her personal capacity as a consultant and as the head of Campaigning for Cancer. But these donor rands come with a contract that exempts the nonprofit from any obligation to serve companies’ agendas, she says.
“Campaigning for Cancer’s advocacy efforts are fiercely independent, patient-centered and effective,” Pretorius maintains.
According to the Presidential Health Compact, this patient group will form part of a “joint technical monitoring team” for the NHI and have a direct line to the NHI war room established by Ramapohsa in February.
The presidency did not respond to requests for comment.
One activist said: “There are no representatives for the patients who will be using the NHI — the people of the country.”
- Read more: The power, the purse strings and the NHI
Pretorius explains that the user group had been created following the Presidential Health Summit, to which she says most patient groups were not invited. Those that had attended had undertaken to draw others into the NHI consultations but this, Pretorius says, never happened.
“As a result, the Presidency reached out to a group of patient groups to ensure we were included in the resulting multi-stakeholder dialogue,” she explains. “This group, plus several other groups, formed what is now known as the ‘User Groups’ constituency.”
She adds: “At a meeting held in December to discuss our involvement, there was a consensus reached that we would participate in the resulting dialogue and compact development but would reserve our approval of the summit report as we had not attended This is what we did.”
But it’s the patients in the far-flung areas of the country who need better quality healthcare the most, Mhlati argues.
He explains: To think that we’re going to fix the quality of care by just changing the way it’s financed — we’re living in a fool’s paradise.”
[Updated 14:00 25 September 2019 This story was updated to clarify that while sexual and reproductive health was included in the final 24 September document, the final 24 September version of the declaration did not mention “sexual and reproductive health and rights”.]
Joan van Dyk was a health journalist, senior health journalist and news editor at Bhekisisa between 2017 and 2023.
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