Keynote Address by Minister of Health, Dr Joe Phaahla, MP, on the occasion of the Policy Dialogue on Universal Health Coverage in South Africa during the Event of Universal Coverage Day

12 December 2022

Programme Director,
Deputy Minister of Health, Dr Sibongiseni Dhlomo, MP,
Director-General, National Department of Health, Dr Sandile Buthelezi,
Chairperson of Portfolio Committee of Health, Dr Kenneth Jacobs,
Members of Portfolio Committee present,
WHO Country Representative, Dr Owen Kaluwa,
MECs of Health present,
Heads of Provincial Health Departments present,
International Development Partners present,
Esteemed Speakers and Panelists,
Distinguished guests
Ladies and gentlemen

Good morning. I am pleased to welcome you all to the first Universal Health Coverage Day event post the onset of the COVID-19 pandemic and more so, to have the opportunity to engage in person with you all on a critical aspect of our health system - attainment of universal health coverage, known to us as UHC.

Approximately half the world’s population lacks access to such essential health services. South Africa, like many countries globally, is striving to achieve UHC in fulfillment of the United Nations' Sustainable Development Goal (SDG) target 3.8. In July 2019, our President, His Excellency Cyril Ramaphosa, launched the ‘Presidential Health Summit Compact’ aimed at strengthening our health system toward an integrated and unified system.

The compact lays out a five-year roadmap for health systems strengthening reforms under ‘9 pillars’ for accelerating UHC in South Africa. These pillars, closely mapped to the WHO Health System Building Blocks, are:

augmenting and better distributing human resources for health;

improving supply chain management to improve access to essential medicines, equipment and supplies;

executing the health infrastructure plan;

engaging the private sector;

involving the community;

improving the health system in terms of quality, safety and quantity;

increasing efficiency in financial management;

developing national health information systems to guide policies, strategies and investment, and

strengthening governance and leadership to ensure accountability.

These pillars also closely approximate the key targets contained in the political Declaration on UHC that was agreed to by Heads of States at the United Nation’s High-Level Meeting (UN-HLM) on UHC during the UN General Assembly (UNGA) in September 2019. These commitments were made a mere few months before the onset of COVID-19, the impact of which is still unfolding our population and health system.

In South Africa, in the immediate term, the need to pivot services to address the burden of COVID-19 has had negative impacts on non-COVID-19 patients and health services. Of the entire service package, routine services for non-communicable diseases (NCDs) were greatly impacted. Follow-up visits for patients with NCDs were postponed and healthcare workers (HCWs) were re-deployed to COVID-19 services. Delays in diagnosis, monitoring and treatment of NCDs, particularly at primary health care (PHC) level has potentially severe implications for people living with NCDs.

In terms of Maternal and Child Health programs, pregnant women attended clinics later in their pregnancies during 2021 than in the previous year. However, while there was no significant change in numbers of antenatal visits, births increased in the same period, showing that some women did not access antenatal care as expected. In addition, maternal and neonatal mortality, which are key health system indicators, have shown increases during the pandemic.

HIV and TB services, which are the most robust vertical programs due to the intensive investment and resource allocation to address the burden of disease, also suffered. Many people did not access these services for a range of reasons including public health measures, such as lockdown, and fear of exposure. Data comparing 2020 to 2019 service utilisation shows consistently low numbers for the 2020 period.

On average, HIV testing declined by 22.3% in 2020 compared to 2019, with the largest decline seen from April to July 2020. Even when lockdown eased, numbers did not reach the levels of the previous years. However, HIV services for those already living with HIV were maintained. TB notifications in South Africa declined by more than 50% and the weekly average of confirmed TB cases decreased by 33%. This decline in testing has significant implications for treatment initiation, linkage to care and reducing transmission of TB and HIV. On the other hand, trauma and injuries decreased by 14.6% in 2020 as compared to 2019, with predictable increases as lockdown levels eased and alcohol bans were lifted.

Despite these challenges, service innovations arose to address the burgeoning need for services. Service delivery for COVID-19 was augmented by drive-through and mobile testing units and vaccination sites, providing possible avenues for future services such as remote TB testing facilities. The Central Chronic Medicines Dispensing and Distribution (CCMDD) model which was already in place prior to COVID-19 saw massive scale up to ensure patients had access to medication.

Local innovations in testing allowed for the development of locally produced COVID-19 tests, decreasing our reliance on the overseas market. Additionally, the usage of technology for self-screening and health education has shown promise in South Africa, although infrastructure challenges do remain a barrier to access. Telehealth and telemedicine, facilitated through a change in regulations issued by the Health Professions Council of South Africa, allowed for remote consultation and monitoring of patients, thereby improving access to care.

It is time now to move our attention towards building a resilient health system that delivers UHC. In tracking countries’ progress, the WHO has developed an indicator which is an index reported on a unitless scale of 0 to 100. This index is computed from 14 tracer indicators of health service coverage. The long-term objective for this indicator is a value of 100. South Africa’s UHC index has almost doubled in the past 20 years, from a score of 36 in 2000 to a score of 67 in 2019.

Considering individual elements it should be noted that service coverage for Maternal and Child Health has remained relatively stable. However, with the prioritisation of communicable diseases due to the HIV/TB epidemics, NCD services have suffered, despite the growing burden due to this disease group. This epidemiological transition, where the pattern of mortality and disease in a population is transformed from high mortality among infants and children to one of degenerative and human-made diseases (such as those attributed to smoking) affecting principally the elderly, alongside the severe inequities present in our country, necessitate drastic reform.

According to the World Bank, South Africa is one of the most unequal countries in the world, with "race" playing a key role in a society where 10% of the population owns more than 80% of the wealth. In South Africa, just over 1% of the population spend over 10% of their household budget on healthcare, and 0.1% spend over 25% of their household budget. Our two-tiered healthcare system consists of a public state-funded sector that serves the majority of the population (approximately 80 to 85%), and a private sector serving around 15 to 20% of the population. The private sector is mostly funded through individual voluntary contributions to medical aid schemes or health insurance. This way of funding the healthcare system leads to inequality. In addition, compared to countries with similar economies to ours, South Africa spends more on health (8,9% of GDP in 2021/21); however, health outcomes are not proportional to the amount spent.

It is clear that UHC is the answer for resilient health systems that ensure quality and equitable access to health care. Countries like Brazil, Canada, Finland, Norway, Sweden, Thailand, Turkey and the United Kingdom have successfully implemented UHC systems. This has significantly improved access to health services and health outcomes. Countries with UHC responded better and quicker to emergencies as seen during COVID-19 pandemic.

The National Health Insurance NHI is South Africa’s chosen route to achieve UHC. The NHI is a health financing system that is designed to pool funds to provide access to quality, affordable personal health services for all South Africans based on their health needs irrespective of their socioeconomic status. The NHI will have the following features:

Universal access: All South Africans will have access to quality health care when and where they need it without suffering financial catastrophe.

Comprehensive services: The NHI will cover a comprehensive set of health benefits that cover a continuum of care.

Financial risk protection: South Africans will not suffer financial hardship in accessing health care services. The NHI seeks to eliminate user fees, co-payments and direct out of pocket payments.

Mandatory prepayment: The NHI will be financed through mandatory prepayment as opposed to current voluntary prepayment and out of pocket payments.

Single fund: All sources of funding will be integrated into the NHI Fund. The multiple public sector funding streams, namely equitable share allocations, conditional grants and locally generated revenues will be integrated into the Fund. The single fund will provide cross subsidization of the rich and poor, young and old, healthy and sick.

Strategic purchaser: As a strategic purchaser, the NHI will proactively identify population needs and efficiently and effectively purchase health goods and services. The advantages of strategic purchasing are enhancement of equity in the distribution of resources, increase efficiency, managed expenditure growth and promotion of quality in health service delivery. The NHI will also serve to enhance transparency and accountability of providers and purchasers to the population.

Single-payer: The NHI Fund is the entity that pays for all health care costs on behalf of the population. The term "single-payer" describes the funding mechanism and not the type of provider.

Canada is an example of a country with a single payer system. The Canadian health system is universal and considers national health insurance and healthcare to be a fundamental human right for all their citizens. The health care system is publicly funded through national, provincial, and territorial taxation. The provinces and territories have primary responsibility for financing, regulating, and administering universal health coverage for their residents.

South Africa seeks a unified single payer system where the NHI Fund is responsible for financing and the provinces (together with private providers) will be responsible for provision of health services. This is to address the current fragmentation in health care in the various provinces to ensure a standardized set of benefit packages for all South Africans.·

the UHC 2030 campaign states (and I quote), “The essence of UHC is universal access to a strong and resilient people-centred health system with primary care as its foundation. Community-based services, health promotion and disease prevention are key components as well as immunization, which constitutes a strong platform for primary care upon which UHC needs to be built.”

Therefore, there needs to be a distinction between the NHI Fund as a financing mechanism and health service strengthening reforms that are currently underway to enhance the ability of the NHI Fund to achieve UHC. These include but are not confined to: Primary Health Care Re-engineering, expanding the service provider base to contract with public and private providers, establishing accreditation, infrastructure, and quality improvement mechanisms as well as private sector reforms in line with recommendations from the Health Market Inquiry.

Taking the above into account, South Africa needs to make strides towards the UHC 2030 targets by doing the following:

Reinforcing the political leadership shown in the commitments highlighted previously that show that South Africa is serious about achieving UHC. We, as the National Department of Health, similarly call on and wish to engage with, all stakeholders at all levels of the health sector as well as our counterparts in other sectors, to ensure that Section 27 of our Constitution is realized. We also re-affirm commitments towards addressing the upstream social determinants of health, to protect our populations from ill-health and promote healthy lives for all.

We acknowledge the vast inequity that permeates every aspect of our society and commit to making the NHI, as the vehicle of UHC, a reality so as to ensure that every person in South Africa is able to access care that is not dependent on their ability to pay.

We have seen the ability of our health system to be adaptive and responsive to the changing needs of our population and health system and we will continue to work with relevant stakeholders to maintain a high level of regulation and governance without compromising on responsiveness to need.

We will continue to support institutions such as the Office of Health Standards Compliance, as well as health facilities, to reach and maintain the desired levels of quality of care that will increase public trust and utilisation of the health system.

We will use the lessons afforded to us during COVID-19 as well as pre-COVID-19 initiatives such as the establishment of the National Public Health Institute of South Africa to strengthen our health system and ensure resilience during public health emergencies.

Lastly, through this dialogue we are opening a necessary conversation amongst South Africans, and all health stakeholders about the necessity of health reforms and the need to implement the NHI to expand the accessibility of the health care system to all. And, I look forward to the outcome of this forum and the varying ideas we have to achieve the Universal Health Coverage.

I thank you

Issued by Department of Health, 12 December 2022