NHI: The road to universal health coverage (South Africa)

Seven years ago the UN endorsed universal health coverage as key to sustainable development and global security.

The South African government has taken up the challenge. President Cyril Ramaphosa has underscored the government’s commitment to introducing South Africa’s version of universal health coverage. He said the revision of a new law to implement National Health Insurance (NHI) was at an “advanced” stage. The aim is to ensure that all in the country have access to quality healthcare, without prejudice or financial detriment.

A long way to go

The country still has a long way to go. A recent report on the 11 districts where the NHI was piloted found that the projects were plagued by problems. Medicine stock levels in clinics and hospitals couldn’t be monitored because there was no internet connectivity and vacant posts couldn’t be filled because they had been frozen. Teams of medical specialists were expensive, overworked and failed to achieve targets of improving infant health.

According to the World Health Organisation (WHO) three features must be present for universal health coverage to be achieved.

The first is that the services provided must be extensive and include health promotion, prevention, treatment, rehabilitation as well as palliative care. The second is coverage, which includes some form of financial risk protection.

The third feature is universality. This means that everyone within the borders of a country must be included. The WHO has emphasised that this means international migrants – irrespective of legal or migration status – must be included too, and afforded access to a minimum of essential and affordable healthcare services.

Migrant population

Rather than addressing its aims of ensuring equitable access to quality healthcare for all, the NHI – in its current form – legitimises the persistent exclusion of international migrants from South Africa’s public health system.

South Africa is home to approximately 2million international migrants, about 4% of the total population in 2011. Most are from elsewhere in the Southern African Development Community( SADC) region and have moved to South Africa in search of work opportunities.

But migrants living in South Africa struggle to access public services – including healthcare. This is the case even though they are legally entitled to these services.

Looking after the health of migrants is good for economic and social development. Excluding international migrants from the public health care system can result in a population-wide risk. Denying a part of the population access to preventive and curative health services, undermines efforts to control infectious diseases – including HIV and tuberculosis..

How can the South African government make sure that international migrants don’t get left behind in efforts towards universal health coverage?

The answer is two-fold. First, South Africa needs to adopt a “migration-aware” approach to the health system and ensure that this is included in the NHI bill.

Second, the country needs to learn from Thailand. Thailand’s successful approach to universal health coverage includes cover for undocumented migrants.

In Thailand, health insurance for documented and undocumented migrants has been introduced, and the provision of migrant-friendly services has been strengthened.

South Africa’s newly appointed Minister of Health, Zweli Mkhize, recently promised a social compact on health. But it remains to be seen if this will reflect the importance of engaging with international migration as the government grapples with finalising its plans for universal health coverage.

This article first appeared in The Conversation – www.theconversation.com